Tranexamic acid formulations

ABSTRACT

Disclosed are immediate release oral tranexamic acid formulations and methods of treatment therewith.

This application is a continuation-in-part of U.S. patent applicationSer. No. 12/220,241, filed Jul. 23, 2008, which is a continuation ofU.S. patent application Ser. No. 11/072,162, filed on Mar. 4, 2005,which claims priority from U.S. Provisional Application No. 60/550,113,filed Mar. 4, 2004, and U.S. Provisional Application No. 60/592,885,filed Jul. 30, 2004, the disclosures of which are hereby incorporated byreference in their entireties.

FIELD OF THE INVENTION

The invention is directed to oral tranexamic acid formulations andmethods of treatment with these formulations.

BACKGROUND OF THE INVENTION

Tranexamic acid (trans-4-(aminomethyl) cyclohexanecarboxylic acid,Cyklokapron® (Pfizer) is an antifibrinolytic agent. That is, it helps toprevent lysis or dissolution of a fibrin clot which forms in the normalphysiologic process of hemostasis. Its mechanism of action is as acompetitive inhibitor of plasminogen activation, and as a noncompetitiveinhibitor of plasmin; both plasminogen and plasmin are activators offibrinolysis and active clot-lysing agents. Tranexamic acid thus helpsto stabilize fibrin clots, which in turn maintains coagulation and helpsto controls bleeding.

Tranexamic acid is used to control excess bleeding, for example, excessbleeding that occurs during dental procedures in hemophiliacs and forheavy bleeding during menstruation (menorrhagia). Women suffering frommenorrhagia are typically treated orally with 500 mg tranexamic acidtablets administered three or four times daily with a total daily dose,ranging from 3 grams/day (two tablets every eight hours) to 6 grams/day(three tablets every six hours). However, this treatment may causeadverse gastrointestinal reactions, including nausea, vomiting,diarrhea, and cramping, etc. These gastrointestinal side effects are dueto the quantity of tranexamic acid and/or rapid rate of release oftranexamic acid, into the stomach with each dose, as well as the largequantity of excipients used in the tablet formulation that areintroduced into the stomach. Such side effects, in addition to thecramping, bloating, pain, and other symptoms that may accompany menses,are undesirable, and a formulation of tranexamic acid is needed whichwill reduce or eliminate these side effects.

Menstrual Bleeding

Menstrual Bleeding disorders encompass a number of conditions includingbleeding associated with uterine fibroids, endometriosis, or bleeding asa result of deficiencies in the clotting process for example,von-Willebrand's disease. Studies suggest that as many as 11% of thewomen who experience heavy menstrual bleeding, suffer from an inheritedbleeding disorder such as von Willebrand's disease. Excessive MenstrualBleeding is menstruation at relatively regular intervals but withexcessive blood loss over the menses period which may be prolonged.Heavy Menstrual Bleeding (also referred to as “Menorrhagia”) is aserious, persistent, and recurrent medical condition that is one of themost common complaints encountered by gynecologists and primary carephysicians (Palep-Singh, 2007). A 2005 surrey of 273obstetrician/gynecologists found that they see an average of 18 to 25symptomatic patients per month. Heavy Menstrual Bleeding is ahyperfibrinolytic condition defined as cyclic, normal intervals ofmenstruation with excessive volume. Menorrhagia is often associated witha disruption in daily routines, work, and sexual activity leading to asignificant decrease in health-related quality of life and time lostfrom work or school. While Menorrhagia is rarely life threatening, whenundiagnosed and untreated, it may over time cause iron deficiency anemiaand increased fatigue, both of which affect normal life activities,relationships, social activities, and various aspects of mentalwell-being (irritation, anxiety). Left untreated it may be associatedwith subsequent morbidity including dysmenorrhea, hospitalization, redblood cell transfusions and chronic pain. Annually, approximately 10% ofwomen of reproductive age report Menorrhagia (Rees 1991; van Eijkeren,1992) and according to the Center for Disease Control (CDC), 3 millionwomen of reproductive age report Menorrhagia yearly, 60% of which haveno known etiology. Studies report that as many as thirty percent ofpremenopausal women perceive their menses to be excessive.

Women suffering from menorrhagia often have greater uterine fibrinolyticactivity than women with normal cyclic menstrual blood loss (MBL). Highconcentrations of plasminogen activators are found in both the uterusand menstrual fluid (Albrechtsen, 1956a,b). Rybo (1966) foundsignificantly higher concentration of endometrial plasminogen activatorsin women with excessive menstrual bleeding compared to women with normalmensal loss.

Causes of Menorrhagia include pelvic diseases (myomata [fibroids],adenomyosis or uterine polyps), intrauterine contraceptive devices, andsystemic disorders (coagulopathies such as thrombocytopenia or vonWillebrand's disease, and hypothyroidism). In contrast to menorrhagia,the term ‘dysfunctional uterine bleeding’ refers to excessive, prolongedor irregular bleeding from the endometrium that is unrelated to systemicdisease (Wathen, 1995), and is usually associated with anovulation.Menorrhagia is also distinguished from other ovulatory bleedingdisorders, such as metrorrhagia (intermenstrual bleeding),menometrorrhagia (irregular heavy menstrual bleeding) and polymenorrhea(menstrual cycle less than 21 days).

Diagnosis of Menstrual Blood Loss

In clinical trials, menstrual blood loss (MBL) is usually determined bymeasuring the amount of hemoglobin recovered from sanitary products duithe menstrual cycle, using the alkaline hematin method Eraser, 1994).However, it is important to remember that blood accounts for only about50% of total menstrual flow, with endometrial transudate accounting forthe remainder (Fraser, 1994). Total menstrual flow can be estimated byweighing of sanitary products or by comparisons with a pictorial bloodloss assessment chart. However, the use of these quantitative andsemi-quantitative methods is not practical in non-trial settings.Rather, the diagnosis of Menorrhagia in the healthcare clinic is made bymedical providers on the basis of patient's perceived and self-reportedmedical history, routine laboratory assessments of the patient's generalhealth status, and gynecological examinations.

Clinically heavy menstrual bleeding is sometimes defined as total bloodloss exceeding about 80ml per cycle or menses lasting longer than sevendays. The volume lost however, varies widely. Clinically losses fromabout 30 ml to 60 ml, 60 to 80 ml, 80 to 100 ml, to as high as 1000 mlper cycle are observed. Menstrual blood losses of 50 to 60 ml areassociated with a negative iron balance and iron deficiency anemia isdiagnosed in about 67% of the women who lose an excess of 80 ml per day.Other criteria for diagnosing the condition include measuring the numberand size of blood clots in the meneges, or monitoring the use of pads ortampons. It is estimated that perhaps only ten percent of women whoperceive their loss to be excessive actually fall within the clinicaldefinition. The 80 ml definition has been repeatedly questioned, andalternative definitions broadened the blood loss range used for patientevaluations.

Blood loss volume assessments commonly require the collection andpreservation of menstrual pads or tampons, the extraction of the padsand the accurate measurement of the blood content. Women are instructedto collect all sanitary towels and tampons during the course of themenstrual diagnosis period or the course of a clinical study period.Blood loss can be measured by extraction of the blood from the sanitarymaterial with 5% sodium hydroxide followed with a spectrophotometricmeasurement of hematin at a wavelength of about 540 nm The total bloodloss can be calculated for an individual by comparison of the patientsplasma blood hemoglobin measurement with the collected hemoglobinvalues.

The collection of the blood sample discourages the routine use of thetest in the diagnosis or in the treatment of the condition. In thecourse of a routine visit with a physician other blood work may beappropriate but lacks a casual relation to the heavy bleeding disorder.The battery of routine laboratory tests may include patient bloodhemoglobin, haematocrit, platelet count, bilirubin, serum creatinine andserum ferritin. In sum, diagnosis in the routine course of practicerelies heavily on the woman's perception of the volume of blood lostduring menses.

Diagnosis and Treatment of Heavy Menstrual Bleeding Disorders(Menorrhagia)

A number of medical and surgical interventions are available to treatmenstrual bleeding disorders Currently available non-surgical treatmentsfor heavy bleeding disorders, include, hormonal treats (e.g., oralcontraceptives), high-dose progestin therapy, desmopressin acetate,ethamsylate, nonsteroidal anti-inflammatory drugs (NSAIDs), theantifibrinolytic drugs aminocaproic acid and tranexamic acid. Even withthe drug treatments available, surgery remains a common treatment.

Although not approved for menorrhagia in the US, use of oralcontraceptives for menorrhagia is widely accepted. Oral contraceptivesmay not be a preferred therapy for some women because of age (youngerfemales), unwanted side effects (nausea and vomiting, breakthroughbleeding, weight change, migraines and depression), and safety concerns(increased risk of thromboembolism, stroke, myocardial infarction,hepatic neoplasia and gall bladder-disease). High-dose progestin(synthetic versions of the hormone progesterone) may also be given towomen with menorrhagia, either orally or by a progestin-releasing deviceinserted into the uterus (intrauterine device). Side effects includenausea, bloating, mood changes, and breast tenderness.

Although it is typically a last resort, desmopressin acetate issometimes used to help lighten menstrual flow in women with menorrhagiaThe effectiveness of desmopressin is thought to wary between individualsSide effects include headache, tachycardia, facial flushing, and rarereports of thromboembolism.

NSAIDs are sometimes used to treat menorrhagia as they may reduce bloodflow while providing analgesia for pain associated with the condition(Shaw, 1994). Side effects associated with chronic NSAID use includegastrointestinal bleeding, ulceration, and perforation; and renaleffects such as hyperkalemia, hyponatremia, acute renal insufficiency,interstitial nephritis, and renal papillary necrosis.

Hysterectomy or endometrial resection are options if other forms oftherapy are not effective or are unsuitable for some reason. Possiblesurgical complications include infection, uterine perforation, and othercomplications associated with major surgery.

Antifibrinolytic drugs, such as ε-aminocaproic acid and tranexamic acid(immediate-release formulation) have been used to treat HMB in womenwith or without a diagnosed bleeding disorder (van Eijkeren, 1992,Bonnar, 1996; Vermylen, 1968; Nilsson, 1965). The available evidencefrom published literature suggests that tranexamic acid at doses of ˜4g/day (typically 1 g every 6 hours) is effective in the treatment of HMBand is associated with few side effects (Callender, 1970; Dunn, 1999;Edlund, 1995; Preston, 1995). In Sweden, the average dose of tranexamicacid to treat HMB is 3.9 g/day (Rybo, 1991). Thus, tranexamic acid isused extensively in Europe, Canada, Asia, Japan, Australia and NewZealand to treat menorrhagia, but is not approved for this indication inthe US.

Tranexamic acid is a competitive inhibitor of plasminogen activation(see review by Dunn, 1999). Binding of tranexamic acid to plasminogendoes not prevent conversion of plasminogen to plasmin by tissueplasminogen activator, but the resulting plasmin/tranexamic acid complexis unable to bind to fibrin. Thus, enzymatic breakdown of fibrin byplasmin (fibrinolysis) is inhibited. At higher concentrations,tranexamic acid is also a noncompetitive inhibitor of plasmin.

Before medical and surgical interventions can be initiated, diagnosis ofa heavy menstrual bleeding disorder must be accomplished.

Diagnosis and treatment of disease often depends on the patient'sperception and subsequent description of symptoms, the physician'sevaluation of the patient's description, the physician observations ofthe patient and laboratory test results. Menstrual bleeding disorders donot lend themselves to physician observation or to routine laboratorytesting. Patient observations and the physician's evaluation of thepatient's description are subjective and thus variable. In addition awomen's medical history has been found to be a poor predictor ofmenstrual blood loss. Neither the duration of menses nor the number ofsanitary pads worn accurately corresponds to the woman's actualmenstrual blood loss (Chimbira, Haynes, year). An objective assessmentof blood loss using the alkaline haematin assay has been shown to bereproducible but it is not suited for routine clinical use by healthcareproviders. To date no effective instrument for reliably diagnosingand/or monitoring the treatment of menstrual bleeding disorders has beendeveloped despite the significant number of women who suffer from theseconditions.

Previously, studies have focused on the impact of symptoms of bleedingdisorders on patients' health related quality of life. As the effects ofmenstrual bleeding disorders are primarily symptomatic, the subjectiveoutcome namely symptom alleviation, cannot be objectively measured. Inresearch from European countries where the antifibrinolytic drugtranexamic acids currently available, treatment with thisantifibrinolytic has reduced heavy menstrual bleeding by 40-50% andimproved the health-related quality of life of affected women onmeasures of social activity, work performance, productivity,cleanliness, overall functioning and tiredness.

Jenkinson et al, Quality in Health Care 1996, 5, 9-12 evaluated thevalidity and internal reliability of the short form-36 (SF36) healthsurvey questionnaire in women presenting with menorrhagia. The studyconcluded that several questions on the questionnaire were difficult toanswer for patients with heavy menstrual bleeding. Such problems weresuggested as possible interferences with the validity of the measure.Jenkinson warns that because a subjective measure works well in onepopulation or with one group, this cannot be taken to imply itsappropriateness for all groups or conditions.

Edlund, in an abstract from a seminar on Dysfunctional Uterine Bleeding,Feb. 23, 1994, indicates that a questionnaire was used in a Swedishstudy of 2205 women who described their menstruation as excessive.

Winkler in a study based in part on the Edlund work, concluded that thetreatment of heavy menstrual bleeding with tranexamic acid increased thequality of life of the treated patients. The Winkler study was an openlabel uncontrolled usage study which included 849 patients. Aquestionnaire was used prior to treatment and after the first and thirdmenstruation. The study indicates that 80% of the women were satisfiedwith the treatment. The questionnaire used a series of eight questioncombined with an assessment by the patients of the change in quantity ofmenstrual flow.

Ruta, D. A., Quality of Life Research 4, (33-40), 1995 finds thatmenorrhagia is a common problem in gynecological practice and that womenseek professional help primarily because of the deleterious effect ontheir quality of life. Ruta recognizing the importance of evaluating theeffectiveness of the treatments developed a questionnaire based on thetype of questions frequently asked when taking a gynecological history.A series of questions were devised which assessed fifteen factorsincluding the duration of the period, the regularity of the period,pain, problems with soiling/staining, interference with work,interference with leisure. Ruta concluded that the clinicalquestionnaire may be useful in selecting patients for hysterectomy andassessing the outcome of conservative treatment especially incombination with the SF-36 questionnaire.

Diagnostic Test for Menstrual Bleeding

The alkaline haematine test described above provides quantitativeassessments of the extent of menstrual bleeding. This test allows thephysician to diagnose and monitor the progress of a women's menstrualprocess. However the test is impractical and difficult to perform. Thetest requires women to capture used menstrual pads over the course ofher period, preserve the samples in a condition such that the bloodcontent within the pad may be accurately extracted and quantitated.Requesting a patient to perform menses sample collection may bepractical in the course of a clinical trial where procedures arespecified and monitored however, in routine medical practice, the use ofsuch a test procedure to diagnose and monitor a women's menstrualbleeding is impractical and the data generated is unreliable.

The need remains to develop an assessment system which replacespreviously studied diagnostic techniques and the alkaline haematine testand provides a reliable measure of both the occurrence of the disorderand the progress of the disorder. The present invention fills this needby providing a Heavy Menstrual Bleeding Instrument (HMBI) which iscapable of diagnosing, and monitoring the treatment of a patient with amenstrual bleeding disorder.

There also remains a need to provide Heavy Menstrual Bleeding (HMB)therapy that is safe, efficacious and only administered during themonthly period of heavy menstruation, addresses the excessivefibrinolysis implicated in many causes of menorrhagia, and fills acurrently recognized unmet medical need in the US. Therapy for HMB isexpected to reduce the incidence and extent of iron-deficiency anemia,and to provide a nonhormonal medical therapy option in lieu of thenumerous invasive procedures (e.g., transcervical endometrial resection)and major surgery (hysterectomy) performed annually.

SUMMARY OF THE INVENTION

It is an object of the invention to provide an oral dosage formcomprising tranexamic acid which is suitable for oral administration ona two or three times a day basis to humans.

It is a further object of certain embodiments of the invention toprovide a method of treating a patient in need of tranexamic acidtherapy with one or more oral dosage forms comprising tranexamic acid.

It is a further object of certain embodiments of the present inventionto provide a method of treating a patient suffering from heavy menstrualbleeding (menorrhagia) by orally administering to the patient one ormore dosage forms comprising tranexamic acid which provide(s) fortherapeutically effective levels of tranexamic acid suitable for two orthree times a day administration.

It is a further object certain embodiments of the invention to provide aformulation comprising an amount of tranexamic acid which when releasedin the gastric contents provides fewer adverse effects than with certaincurrent tranexamic acid therapy.

The above advantages and objects and others can be achieved by virtue ofthe present invention which is directed in part to a method of treatinga patient in need of tranexamic acid therapy comprising administering tothe patient about 1300 mg of tranexamic acid or pharmaceuticallyacceptable salt thereof in one or more oral dosage forms including thetranexamic acid or pharmaceutically acceptable salt thereof such thatthe dose administered provides a mean maximum plasma concentration(C_(max)) of tranexamic acid of from about 9 to about 15 mcg/ml,preferably from about 10 to about 14 mcg/ml, more preferably about 12mcg/ml after single dose oral administration to humans.

In certain embodiments, the invention is directed to an oral dosage formcomprising 650 mg of tranexamic acid or pharmaceutically acceptable saltthereof which provides a mean maximum plasma concentration (C_(max)) oftranexamic acid of from about 9 to about 15 mcg/ml, preferably fromabout 10 to about 14 mcg/ml, more preferably about 12 mcg/ml per 1300 mgof tranexamic acid after single dose oral administration to humans.

In certain embodiments, the invention is directed to an oral dosage formcomprising 650 mg of tranexamic acid or pharmaceutically acceptable saltthereof which provides a mean T_(max) of tranexamic acid at from about 2to about 4 hours, preferably at about 3 hours after oral administrationto humans.

In certain embodiments, the invention is directed to an oral dosage formcomprising about 650 mg of tranexamic acid or pharmaceuticallyacceptable salt thereof and a pharmaceutically acceptable excipient,said dosage form providing an in-vitro dissolution release rate of thetranexamic acid, when measured by a USP 27 Apparatus Type II PaddleMethod@50 RPM in 900 ml water at 37±0.5° C., of at least about 70% byweight tranexamic acid or pharmaceutically acceptable salt thereof orreleased at about 45 minutes, and preferably 100% by weight tranexamicacid or pharmaceutically acceptable salt thereof release by about 45minutes.

In certain embodiments, the invention is directed to an oral dosage formcomprising about 650 mg of tranexamic acid or pharmaceuticallyacceptable salt thereof and a pharmaceutically acceptable excipient,said dosage form providing an in-vitro dissolution release rate of thetranexamic acid or pharmaceutically acceptable salt thereof from thedosage form, when measured by the USP 27 Apparatus Type II PaddleMethod@50 RPM in 900 ml water at 37±0.5° C. of about 0% to about 95% byweight tranexamic acid or pharmaceutically acceptable salt thereofreleased at about 15 minutes, from about 30% to about 100% by weighttranexamic acid or pharmaceutically acceptable salt thereof released atabout 30 minutes, from about 70% to about 100% by weight tranexamic acidor pharmaceutically acceptable salt thereof released at about 45minutes, about 100% by weight tranexamic acid or pharmaceuticallyacceptable salt thereof released at about 60 minutes.

In certain embodiments, the invention is directed to an oral dosage formcomprising about 650 mg of tranexamic acid or pharmaceuticallyacceptable salt thereof and a pharmaceutically acceptable excipient,said dosage form providing an in-vitro dissolution release rate of thetranexamic acid or pharmaceutically acceptable salt thereof from thedosage form, when measured by the USP 27 Apparatus Type II PaddleMethod@50 RPM in 900 ml water at 37±0.5° C. of about 50% to about 95% byweight tranexamic acid or pharmaceutically acceptable salt thereofreleased at about 15 minutes, from about 70% to about 100% by weighttranexamic acid or pharmaceutically acceptable salt thereof released atabout 30 minutes, from about 80% to about 100% by weight tranexamic acidor pharmaceutically acceptable salt thereof released at about 45minutes, abut 100% by weight tranexamic acid or pharmaceuticallyacceptable salt thereof released at about 60 minutes.

In certain embodiments, the invention is further directed to an oraldosage form comprising tranexamic acid (preferably in an amount of about650 mg) or pharmaceutically acceptable salt thereof and apharmaceutically acceptable excipient, which provides for abioavailability of tranexamic acid of greater than 40%, from about 41%to about 60%, preferably from about 42% to about 50%, more preferablyabout 46% after oral administration to humans.

In certain embodiments, the invention is further directed to an oraldosage form comprising about 650 mg of tranexamic acid orpharmaceutically acceptable salt thereof and a pharmaceuticallyacceptable excipient, the dosage form being suitable for oraladministration on a twice a day basis, and the dosage form providing amean maximum plasma concentration (C_(max)) of tranexamic acid of fromabout 13.5 to about 22.5 mcg/ml, preferably from about 15 to about 21mcg/ml, more preferably about 18 mcg/ml per 1950 mg tranexamic acidafter single dose oral administration to humans.

In certain embodiments, the invention is further directed to a method oftreating a patient with a therapeutically effective amount of tranexamicacid or pharmaceutically acceptable salt thereof comprisingadministering to the patient two or three dosage forms of the presetinvention, each dosage form comprising from about 585 mg to about 715 mgof tranexamic acid or pharmaceutically acceptable salt thereof,preferably about 650 mg tranexamic acid or pharmaceutically acceptablesalt thereof, and a pharmaceutically acceptable excipient.

In certain embodiments, the invention is directed to a dose oftranexamic acid or pharmaceutically acceptable salt thereof comprisingtwo oral dosage forms, each oral dosage form comprising from about 585mg to about 715 mg, preferably about 650 mg of tranexamic acid orpharmaceutically acceptable salt thereof, and a pharmaceuticallyacceptable excipient, the dose providing a therapeutic effect whenadministered three times a day.

In certain embodiments, the invention is directed to a dose oftranexamic acid or pharmaceutically acceptable salt thereof comprisingthree oral dosage forms, each oral dosage form comprising from about 585mg to about 715 mg, preferably about 650 mg of tranexamic acid orpharmaceutically acceptable salt thereof, and a pharmaceuticallyacceptable excipient, the dose providing a therapeutic effect whenadministered twice a day.

In certain preferred embodiments, the oral dosage form of the inventionfurther provides a mean transit time of said tranexamic acid of7.21±1.01 hours when administered across a patient population.

In certain preferred embodiments, the oral dosage form of the inventionfurther provides a mean absorption time of said tranexamic acid of3.70±0.94 hours when administered across a patient population

In certain embodiments, the invention is further directed to an oraldosage form comprising tranexamic acid or pharmaceutically acceptablesalt thereof and at least one pharmaceutically acceptable excipientwhich provides less than about 20 percent incidence of nausea, less thanabout 15 percent incidence of nausea, preferably less than about 10percent incidence of nausea as a side effect after single dose oraladministration across a patient population.

In certain embodiments the dosage form provides less CNS side effects(e.g., headache), less GI side effects (e.g., nausea), or combinationthereof in comparison to a therapeutically equivalent amount oftranexamic acid administered intravenously in five minutes or less whenadministered across a patient population.

In certain preferred embodiments, the therapeutically effective dose ofthe tranexamic acid is provided via the administration of two or moredosage units. For example, if the dosage unit comprises 650 mg oftranexamic acid and the dose for administration is about 1300 mg thentwo dosage units would be administered to a patient in need of suchtreatment, or for example, when the dose for administration is 1950 mg,three dosage units would be administered.

In certain preferred embodiments, the invention is further directed to amethod of treating a patient with one or more oral dosage formscomprising tranexamic acid or pharmaceutically acceptable salt thereofand a pharmaceutically acceptable excipient, wherein the oral dosageform provides a therapeutically effective plasma level of tranexamicacid in accordance with a three times a day (TID) dosing schedule, andthe therapeutically effective dose administered comprises about 1300 mgof tranexamic acid.

In certain preferred embodiments, the invention is further directed to amethod of treating a patient with one or more oral dosage formscomprising tranexamic acid or pharmaceutically acceptable salt thereofand a pharmaceutically acceptable excipient, wherein the oral dosageform provides a therapeutically effective plasma level of tranexamicacid in accordance with a twice a day (BID) dosing schedule, and thetherapeutically effective dose administered comprises about 1950 mg oftranexamic acid.

In certain embodiments, the tranexamic acid for use in the methods andformulations of the present invention is in the form of apharmaceutically acceptable salt thereof. Such salt forms include forexample and without limitation the sodium salt, potassium salt, calciumsalt, magnesium salt and the like; as well as the hydrochloride,hydrobromide, sulfate, phosphate, formate, acetate, trifluoroacetate,maleate, tartrate, methanesulfonate, benzenesulfonate,p-toluenesulfonatemethanesulfonate salt forms, and the like. Preferablythe active ingredient for use in accordance with the present inventionis tranexamic acid.

The term “C_(max)” unless otherwise indicated is meant for purposes ofthe present invention to mean the maximum plasma concentration of amedicament achieved after single dose administration of a dosage form,or the maximum plasma concentration of a medicament achieved over adosing interval from multiple-doses at steady-state in accordance withthe present invention.

The term “T_(max)” is meant for purposes of the present invention tomean the elapsed time from administration of a dosage form to the timethe C_(max) of the medicament is achieved.

The term “steady state” means that the amount of the drug reaching thesystem is approximately the same as the amount of the drug leaving thesystem. Thus, at “steady-state”, the patient's body eliminates the drugat approximately the same rate that the drug becomes available to thepatient's system through absorption into the blood stream.

The term “mean” for purposes of the present invention, when used todefine a pharmacokinetic value (e.g., T_(max)), unless specifiedotherwise, represents the arithmetic mean value measured across apatient or subject population.

The term “three times a day (TID) basis” for purposes of the presentinvention, means that the dosage regimen is to be administered threetimes a day, preferably on a schedule of every 8 hours.

The term “mean transit time” is understood by those skilled in the artand means the time-point where 63.2% of the total AUC is attained afteroral administration, or 63.2% of the IV dose is eliminated, as describedin Applied Pharmacokinetics, Principles of Therapeutic Drug MonitoringSecond Edition (1986), edited by William E. Evans, et al., thedisclosure of which is hereby incorporated by reference in its entirety.

The term “mean absorption time” is understood by those skilled in theart and means a quantitative parameter which summarizes how long, onaverage, the drug molecule remains unabsorbed, i.e. persists in itsdosage form and GI tract, also as described in Applied Pharmacokinetics,Principles of Therapeutic Drug Monitoring Second Edition (1986), editedby William E. Evans, et al. Its value is not affected like the drug'sabsorption rate constants (ka), which can be skewed, due to incompleterelease of drug from its dosage form, irregular absorption, lag-time,mixed zero-order dissolution rates, changing GI motility, GI blood flow,first-pass effect, etc.

“Therapy” for excessive menstrual bleeding is defined for the purpose ofthis invention as one or more courses of treatment with anantifibrinolytic agent such as, but not limited to, tranexamic acid,aminocaproic acid, and any pharmaceutically acceptable salts, esters,derivatives, pro-drugs, metabolites, and analogues of any of theforegoing antifibrinolytic agents.

The term “heavy menstrual bleeding” is defined for purposes of thepreset invention as a perceived blood loss of at least heavy to veryheavy which may correspond to a periodic blood loss of at least about 30ml per cycle to as much as 1000 ml per cycle as measured by the alkalinehematin test. The periodic blood loss perceived or as measured with thealkaline hematin test may vary depending on the severity of thecondition and the physiological make up of the individual patient.Therefore, heavy menstrual bleeding may include periodic blood losses ofat least about 30 ml per cycle. Losses from between about 30 ml, about40 ml, about 50 ml, about 60 ml, about 70 ml, about 80 ml, about 90 mlto about 300 ml are contemplated as are losses greater than 300 ml, suchas for example, losses between about 300 ml to about 1000 ml.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 depicts mean plasma concentration-time profiles on a semi-logscale over 36 hours for the formulations of Examples 1 and 2 compared toIV tranexamic acid (Cyklokapron).

FIG. 2 depicts mean plasma concentration-time profiles on a linear scaleover 36 hours for the formulations of Examples 1 and 2 compared to IVtranexamic acid (Cyklokapron).

FIG. 3 depicts the dissolution profiles of the modified releasetranexamic acid formulation of Example 2; the immediate releasetranexamic acid formulation of Example 1; the delayed release tranexamicacid formulation of Example 3A, and the commercial Cyklokapron immediaterelease formulation of Example 4A.

FIG. 4 is a listing of the Menorrhagia Impact Measures of the presentinvention.

FIG. 5 is a graph of Menorrhagia Instrument measure #1 percentage ofpatients and normals indicating each response at baseline (BL) and atone (1) month (M1) from Example 5.

FIG. 6 is a graph of the limitations of social and leisure activities(LSLA) in women with Heavy Menstrual Bleeding (HMB) in accordance withthe treatment regimens administered in Examples 5A and 5B.

FIG. 7 is a graph of the mean menstrual blood loss change from theclinical studies of Example 5A and 5B.

DETAILED DESCRIPTION

The tranexamic acid (API) utilized in the formulations of the presentinvention is available from various manufacturers. The tranexamic acidparticles utilized in the present invention may range from about 0.1 toabout 550 microns. For example, the tranexamic acid particles may have aparticle size range from <about 0.5 to about 520 microns.

The tranexamic acid particles utilized in the present invention may havea D₂₅ particle size distribution ranging from about 5 to about 15microns, a D₅₀ particle size distribution ranging from about 14 to about73 microns, and a D₇₅ particle size distribution ranging from about 30to about 205 microns.

The particle size of the tranexamic acid utilized may also have aparticle size range wherein about 1% of the particles are of a sizegreater than about 250 microns, about 8% of the particles are of a sizeof about 180 microns, about 9% of the particles are of a size of about150 microns, about 4% of the particles are of a size of about 125microns, about 20% of the particles are of a size of about 75 microns,about 14% of the particles are of a particle size of about 45 microns,and about 44% of the particles are of a particle size less than about 45microns.

The tranexamic acid utilized may also have a particle size range whereinabout 5% of the particles are of a size greater than about 250 microns,about 12% of the particles are of a size of about 180 microns, about 14%of the particles are of a size of about 150 microns, about 14% of theparticles are of a size of about 125 microns, about 29% of the particlesare of a size of about 75 microns, about 12% of the particles are of aparticle size of about 45microns, and about 14% of the particles are ofa particle size less than about 45 microns.

The tranexamic acid utilized may also have a particle size range whereinabout 2% of the particles are of a size greater than about 250 microns,about 7% of the particles are of a size of about 180 microns, about 9%of the particles are of a size of about 150 microns, about 4% of theparticles are of a size of about 125 microns, about 20.5% of theparticles are of a size of about 75 microns, about 16% of the particlesare of a particle size of about 45 microns, and about 41.5% of theparticles are of a particle size less than about 45 microns.

The tranexamic acid utilized may also have a particle size range whereinabout 0% of the particles are of a size greater than about 250 microns,about 5% of the particles are of a size of about 180 microns, about 12%of the particles are of a size of about 150 microns, about 11% of theparticles are of a size of about 125 microns, about 31% of the particlesare of a size of about 75 microns, about 17% of the particles are of aparticle size of about 45 microns, and about 24% of the particles are ofa particle size less than about 45 microns.

The tranexamic acid utilized may also have a particle size range whereinabout 20% of the particles are of a size of about 125 microns, about 20%of the particles are of a size of about 75 microns, about 20% of theparticles are of a particle size of about 45 microns, and about 45% ofthe particles are of a particle size less than about 45 microns.

The dosage regimen typically listed for tranexamic acid in HMB (HeavyMenstrual Bleeding) therapy is 1-1.5 g per dose administered three-fourtimes a day at the onset of copious menstrual bleeding and continued forthe first 3-5 days of the menstrual cycle. However, the most frequentlyreported dosage regimen of tranexamic acid is an immediate release oralformulation in which 1 g tranexamic acid is administered four times aday (4 g per day) for HMB therapy outside of the US. Knowledge of thiscommon regimen is supported by a careful review of the randomizedcontrolled trials published in the medical literature, product labelingfrom other countries' regulatory authorities having the product approvedfor HMB therapy, utilization data from Sweden (Rybo 1991),correspondence and interviews with non-US clinicians having experiencewith the product. That regimen is currently the dosage being studied bythe US Center for Disease Control (CDC) in women with HMB associatedwith bleeding disorders.

The absolute bioavailability of tranexamic acid observed whenadministering the European commercial formulation (Cyklokapron, KAbi AB,Sweden Batch 90288; assay 499 mgm/tablet) to male subjects isapproximately 35% and its elimination correlates with renal creatinineclearance. Peak serum tranexamic acid concentrations occur approximately3 hours after the oral administration of a European immediate-releasetablet formulation (>85% dissolved at 15 minutes) (Pilbrant, et al.,Eur. J. Clin. Pharmacol. (1981)-20:65-72). By comparison, the in vivoabsorption profile observed with the European immediate-releaseformulation is slow and very gradual over 3 hours. Specifically,tranexamic acid serum concentrations are 9, 41, 73, 88 percent (withfood), and 22, 63, 85, and 98 percent (fasting) of maximal absorption at0.5, 1, 1.5 and 2 hours after a 2 g oral dose, respectively. Althoughnot wishing to be held to any specific theory, it is presentlyhypothesized that tranexamic acid oral absorption appears to becontrolled by a non-dissolution rate limited process, i.e. the rate andextent of oral absorption is a function of a transmembranepassage-limited process, in order to explain the disparity between thetime of product dissolution and relatively prolonged tmax (time toachieve the peak serum concentration).

Preferably, the goal of the formulation, dose strength and dosageregimen of the invention, is to provide HMB therapy which achieves fromabout 20% to 100% reduction in menstrual blood loss per menstrual cycle.

In accordance with the present invention an oral dosage form comprisingabout 650 mg of tranexamic acid is disclosed. Preferably, the oraldosage form contains at least one pharmaceutically acceptable excipient.

In certain embodiments, the oral dosage form of the present inventionprovides for an increased bioavailability as compared to other immediaterelease oral dosage forms currently available (e.g., Cyclokapron). Incertain preferred embodiments the increased bioavailability allowstherapeutic plasma levels of tranexamic acid to be reached with a lowerdose of drug. Preferably, the increased bioavailability also decreasesthe amount of tranexamic acid that remains unabsorbed in thegastrointestinal which leads to decreased incidence of side effects thatare typically associated with formulations that provide higher levels ofunabsorbed tranexamic acid and prolonged exposure of thegastrointestinal tract to the higher tranexamic acid levels. Preferablythe oral dosage form of the present invention provides for abioavailability of tranexamic acid of greater than 40%, from about 41%to about 60%, preferably from about 42% to about 50%, more preferablyabout 46% after oral administration to humans.

In certain embodiments, the tranexamic acid included in the dosage formis from about 520 mg to about 1500 mg, preferably from about 520 mg toabout 1000 mg. In one embodiment, the dose of tranexamic acid per tabletis in the range of about 520 mg to about 1000 mg for tablets and fromabout 520 mg to about 1500 mg for a sachet filled with granules. Inanother embodiment, the dose of tranexamic acid is in the range of about3 grams/day to about 6 grams/day in three or four divided doses. As anexample, a total daily dose of 3 grams tranexamic acid may be dividedinto three doses of one tablet each with each tablet containing 1 gramtranexamic acid, or may be divided into four doses of one tablet eachwith each tablet containing 0.75 gram tranexamic acid. As anotherexample, a total daily dose of 4 gram tranexamic acid may be dividedinto three doses of two tablets at each dose with each tablet containing0.666 gram tranexamic acid, or may be divided into four doses of onetablet each with each tablet containing 1 gram tranexamic acid. Asanother example, a total daily dose of 5 gram tranexamic acid may bedivided into three doses of one tablet each with each tablet containing1.66 gram tranexamic acid, or may be divided into four doses of twotablets each with each tablet containing 0.625 gram tranexamic acid. Asanother example, a total daily dose of 6 gram tranexamic acid may bedivided into three doses of two tablets each with each tablet containing1 gram tranexamic acid, or may be divided into four doses of two tabletseach with each tablet containing 0.75 gram tranexamic acid. For ease ofswallowing, the dose of tranexamic acid taken at each dosing time may bedelivered by taking multiple tablets. For example, the 4 gram daily dosemay be delivered by taking two 666.67 mg tablets three times a day.Similarly, the 3 gram daily dose may be achieved by taking two 550 mgtablets three times a day. Additionally, a 1.95 g. gram daily dose maybe achieved by taking three 650 mg tablets a day. Alternatively, forease of reference, a dose of 600 mg, 650 mg, or 700 mg of tranexamicacid per tablet may be used. In a preferred embodiment, a total dailydose of 3900 mg/day is administered in three divided doses of 1300 mg oftwo tablets at each dose with each tablet containing 650 mg oftranexamic acid. Alternatively, each dose may be delivered by takinggranules containing the prescribed amount of tranexamic acid presentedin a convenient unit dose package. Such examples are not limiting andother doses within these ranges will be appreciated by those skilled inthe art.

Since tranexamic acid is primarily eliminated via the kidneys byglomerular filtration with more than 95% excreted unchanged drug in theurine, dosage adjustment may be recommended. The table below lists somerecommended dosage adjustments for renal impairment:

Serum Estimated Creatinine GFR* Total daily (mg/dl) (ml/min) Adjusteddose dose 1.4 to 2.8 30-60 1.3 g (two 650 mg tablets) BID 2.6 g 2.8 to5.7 15-30 1.3 g (two 650 mg tablets) QD 1.3 g >5.7 <15 1.3 g (two 650 mgtablets) every 0.65 g  48 hours or 650 mg (one tablet) every 24 hours

In certain embodiments, the invention is directed to a method ofproviding a tranexamic acid plasma concentration within the range ofabout 5 mcg/mL to about 15 mcg/mL by administration of at least oneformulation of the present invention comprising tranexamic acid andpharmaceutically acceptable excipient on a three times a day basis to apatient in need of tranexamic acid treatment.

In certain embodiments, the invention is further directed to a method oftreating a human patient with heavy menstrual bleeding (e.g.,menorrhagia) comprising administering about 1300 mg of tranexamic acidon a three times a day basis to the human patient to provide atranexamic acid plasma concentration within the range of about 5 mcg/mLto about 15 mcg/mL after steady state oral administration to a humanpatient.

In certain embodiments, the invention is directed to a method oftreating a patient suffering from menorrhagia, including patients withheavy menstrual bleeding due to fibroids, conization of the cervix,epistaxis, hyphema, hereditary angioneurotic edema, a patient with ablood coagulation disorder undergoing dental surgery, combinationsthereof, and the like, by administering at least one dosage form of thepresent invention to the patient in need in tranexamic acid therapy.

In certain embodiments, the invention is directed to a method oftreating heavy menstrual bleeding with a therapeutically effective doseof at least one oral formulation of the present invention comprisingtranexamic acid and a pharmaceutically acceptable excipient wherein themenstrual blood loss per menstrual cycle is reduced by at least about 10ml, preferably at least about 20 ml, more preferably at least about 40ml. In a most preferred embodiment the menstrual blood loss permenstrual cycle is reduced by greater than or equal to about 50 ml.

In certain embodiments, the invention is directed to a method oftreating heavy menstrual bleeding with a therapeutically effective doseof at least one oral formulation of the present invention comprisingtranexamic acid and a pharmaceutically acceptable excipient which uponoral administration to a human female reduces the blood loss permenstrual cycle by about 35 ml to about 200 ml, preferably about 40 mlto about 175 ml, more preferably from about 50 ml to about 150 ml.

In certain embodiments, the invention is further directed to a method oftreating heavy menstrual bleeding with a therapeutically effective doseof at least one oral formulation of the present invention comprisingtranexamic acid and a pharmaceutically acceptable excipient which uponoral administration to a human female reduces the blood loss permenstrual cycle by about 20% to 100%, preferably from about 20% to about70%.

The menstrual blood loss can be measured by procedures known in the art.For example, in certain embodiments, the menstrual blood loss can bedetermined by a procedure described by (i) L. Hallbert, et al. in“Determination of Menstrual Blood Loss”, Scandinav. J. Clin. & Lab.Investigation, 244-248, 16, 1964, wherein the procedure is performed byextracting the menstrual blood from vaginal tampons and towels with asodium hydroxide solution, converting heme chromogens to alkalinehematin, which is determined spectrophotometrically, or (ii) themenstrual blood loss can be determined by a procedure described by J.Newton, M.D., et al., in “A Rapid Method for Measuring Menstrual BloodLoss Using Automatic Extraction.”, Contraception, 269-282, September1977, Vol. 16, No. 3, wherein the procedure is based upon the formationof alkaline haematin after the blood has been extracted from vaginaltampons and sanitary towels by an automatic Stomacher Lab-Blender. Thedisclosures of the aforementioned articles are hereby incorporated byreference in their entireties.

The oral dosage forms of the present invention may be prepared astablets, capsules, granules, pellets, powders, pellets, dragees,troches, non-pariels, pills or encapsulated suspension, and may bepackaged into capsules, sachets, etc.

Tranexamic acid oral dosage forms of the present invention areformulated to provide about a 650 mg dose of tranexamic acid. Typically,two oral dosage forms are administered to a patient in need oftranexamic acid therapy to provide a total dose of about 1300 mg. Inaddition, at least one pharmaceutically acceptable excipient is includedin the oral dosage form. The pharmaceutically acceptable excipient mayinclude, for example and without limitation, preservatives, diluents(e.g., microcrystalline cellulose), lubricants (e.g., stearic acid,magnesium stearate, and the like), binders (e.g., povidone, starch, andthe like), disintegrants (e.g, croscarmellose sodium, corn starch, andthe like), glidants (e.g., talc, colloidal silicon dioxide, and thelike), granulating aids, colorants, and flavorants that are conventionalin the pharmaceutical art. Specific examples of pharmaceuticallyacceptable excipients that may be used to formulate oral dosage formsare described in the Handbook of Pharmaceutical Excipients, AmericanPharmaceutical Association (2003), incorporated by reference herein.

Examples of diluents include dextrose, sucrose, starch, powderedcellulose, lactose, mannitol, microcrystalline cellulose, combinationsthereof, and the like.

Examples of lubricants include magnesium stearate, calcium stearate,oleic acid, caprylic acid, stearic acid, magnesium isovalerate, calciumlaurate, magnesium palmitate, behenic acid, glyceryl behenate, glycerylstearate, sodium stearyl fumarate, potassium stearyl fumarate, zincstearate, combinations thereof and the like.

Examples of disintegrants include crospovidone, alginates, cellulose andits derivatives, clays, polyvinylpyrolidone, polysaccharides, such ascorn and potato starch, dextrins, croscarmellose sodium, sugars,combinations thereof, and the like.

Binders, when added to the formulation, promote granulation and/orpromote cohesive compact during the direct compression into tablets.Examples of binders include povidone, acacia, cellulose derivatives,gelatin, glucose, polyvinylpyrrolidone, sodium alginate and alginatederivatives, sorbitol, starch, combinations thereof, and the like.

As used herein, alleviation of adverse effects using these formulationsindicates any relief in one or more symptoms, such as decrease inincidence, severity, or duration of symptoms, and is not limited toabsence of symptoms or elimination of symptoms. Thus, treatment includesany decrease in incidence, duration, intensity, frequency, etc. ofadverse gastrointestinal symptoms including, but not limited to,headache, nausea, vomiting, diarrhea, constipation, cramping, bloating,and combinations thereof. The formulations may reduce symptoms at anytime during tranexamic acid therapy, but minimized adverse effects areparticularly noted immediately or shortly after dosing, that is, withinthe first few hours after dosing. As used herein, adversegastrointestinal effects and side effects are used interchangeably toindicate nontherapeutic effects (i.e., not relating to any possiblebeneficial effects due to tranexamic acid), ranging from unpleasant buttolerable sensations to severe gastrointestinal symptoms. As usedherein, the terms oral formulations, ingestible formulations, and orallyadministered formulations are used interchangeably and include anydosage forms which are ingested by mouth, including, but not limited to,tablets, pills, liquids, gelcaps, dragees, capsules, powders, granules,pellets, etc.

In certain embodiments, the formulation includes tranexamic acid in therange of about 50% by weight to about 95% or more by weight of theformulation. In other embodiments, tranexamic acid is in the range ofabout 60% by weight to about 90% by weight, or about 60% by weight toabout 80% by weight of the formulation. The remaining weight may be madeup of the pharmaceutically acceptable excipient.

To prepare formulations of the present invention, the pharmaceuticallyacceptable excipient may be incorporated into e.g., a tablet matrix withthe tranexamic acid or coated onto e.g., the tranexamic acid or both. Incertain embodiments, tablet formulations are formulated by granulating ablend of powders of the pharmaceutically acceptable excipient and thetranexamic acid. The powder blend is formed by combining portions of thepowdered components that make up the tablet. These powders areintimately mixed by dry-blending. The dry blended mixture is granulatedby wet mixing of a solution of a binding agent with the powder blend.Following granulation, the particles are removed from the granulator andplaced in a fluid bed dryer, a vacuum dryer, a microwave dryer, or atray dryer for drying. Drying conditions are sufficient to removeunwanted granulating solvent, typically water, or to reduce the amountof granulating solvent to an acceptable level. Drying conditions in afluid bed dryer or tray dryer are typically about 50 to 70° C. Thegranulate is dried, screened, mixed with additional excipients such asdisintegrating agents, flow agents, or compression aids and lubricantssuch as talc, stearic acid, or magnesium stearate, and compressed intotablets.

In certain embodiments, the tablet may be coated with an optionalfilm-forming agent. This applied film may aid in identification, mask anunpleasant taste, allow desired colors and surface appearance, provideenhanced elegance, aid in swallowing, etc. The amount of film-formingagent may be in the range of about 2% tablet weight to about 4% tabletweight. Suitable film-forming agents are known to one skilled in the artand include hydroxypropyl cellulose, cellulose ester, cellulose ether,one or more acrylic polymer(s), hydroxypropyl methylcellulose, cationicmethacrylate copolymers (diethylaminoethyl)methacrylate/methyl-butyl-methacrylate copolymers such as Eudragit E®(Rohm Pharma) and the like. The film-forming agents may optionallycontain colorants, plasticizers, fillers, etc. including, but notlimited to, propylene glycol sorbitan monooleate, sorbic acid, titaniumdioxide, and one or more pharmaceutically acceptable dye(s).

In certain embodiments, tranexamic acid tablets are formulated by dryblending, rotary compacting, or wet granulating powders composed oftranexamic acid and tablet excipients. These powders are compressed intoa tablet.

Alternatively, the tranexamic acid formulations may be administered bypellets or granules in e.g., a sachet or capsule. Tranexamic acidpellets or granules may be prepared by using the pharmaceuticallyacceptable excipient to form a granule or pellet matrix U.S. Pat. Nos.5,650,174; and 5,229,135 each of which is expressly incorporated byreference herein in its entirety, discloses variations on fabricating apellet or nonpareil dosage form. Spheres are filled into packets, termedsachets, or capsules which are filled by weight to contain theprescribed dose of drug.

In certain embodiments, the tranexamic acid formulations of the presentinvention may be used for additional indications other than menorrhagia,such as conization of the cervix, epistaxis, hyphema, hereditaryangioneurotic edema, a patient with a blood coagulation disorderundergoing dental surgery, combinations thereof, and the like.

Alternatively the tranexamic acid formulations of the invention may beadministered as pellets or granules in for example a sachet or capsule.

Additional tranexamic acid formulations are disclosed in U.S. patentapplication Ser. No. 12/228,489, filed Aug. 13, 2008; and Ser. No.11/346,710, filed Feb. 3, 2006, the disclosures of which are herebyincorporated by reference in their entirety.

Menorrhagia Instrument

With regard to the treatment of menorrhagia (Heavy Menstrual Bleeding)studies of the safety and efficacy of the antifibrinolytic tranexamicacid were conducted. As part of these studies a diagnosis and treatmentinstrument (Menorrhagia instrument; MI) was designed. The instrumentreliably identifies and monitors heavy menstrual bleeding patients andcan be used in conjunction with an antifibrinolytic agent to diagnoseand monitor the treatment of heavy menstrual bleeding.

A Menorrhagia Instrument (MI) of the invention reliably captures thediagnosis and treatment of the disease by measuring the impact oftreatment on the symptoms associated with heavy menstrual bleeding. Theinformation obtained from individual patient responses to the measuresdescribed in the methods of the present invention correlates to bloodloss as measured by the alkaline hematin test. For example, data fromthe measures of social, leisure and/or physical activity symptoms,correlate with the volume of blood loss, and the change in the intensityof these symptoms correlates with the change in volume of blood lost,thus providing a measurement for the successful diagnosis and evaluationof treatment of bleeding disorders.

The instrument of the present invention measures specific aspects of thepatient's monthly menstrual period. The measures correlate with thediagnosis of heavy menstrual bleeding and with the course ofantifibrinolytic treatment. Further each of the measures individuallycorrelate with quantity of blood loss as measured by the alkalineHematin test. The symptomatic measures include: 1) a functionalassessment measure; and ii) a pharmacology (or therapy assessment)measure.

The functional assessment measure of symptoms is further factored intosegments which include 1) a measure of functional impairment generally;2) impairment of necessary activities; and 3) impairment ofdiscretionary activities.

The pharmacology domain provides an assessment of the severity of themenstrual period.

Specific symptomatic measures may be directed to an initial patientassessment and to the treatment period (pharmacology measure). Examplesof specific measures would include examples of initial patientassessment measures (measures 1-4 listed in the Menorrhagia Instrumentof FIG. 4); and therapy assessment measures (measures 1-4 together withmeasures 6, 6 a, 6 b and 6 c contained in the Menorrhagia Instrument ofFIG. 4).

In certain embodiments, the present invention is directed to a method ofdiagnosing and treating heavy menstrual bleeding, wherein the initialdiagnoses of heavy menstrual bleeding is accomplished by evaluation ofthe most recent menstrual period on the basis of one, some or all of theprescribed symptomatic measures of FIG. 4. Measures which may be used aspart of the initial patient assessment include, for example: a)determining a patient's perceived blood loss during their most recentmenstrual period; b) determining how much the patient's blood losslimited their work outside and inside the home; c) determining how muchthe patient's blood loss limited their physical activities; d)determining how much the patient's blood loss limited their social andleisure activities; and e) determining the specific activities that werelimited by the patient's blood loss.

The assessment of the patient's perceived blood loss during their mostrecent menstrual period may include an inquiry such as “during your mostrecent menstrual period, your blood loss was”. The assessment may thenquantify the patient response as a blood loss that was: i) light, ii)moderate, iii) heavy, or iv) very heavy. Alternatively, the measure maybe quantified in terms of a scale of from one to four where onerepresents light, two represents moderate, three represents heavy andfour represents very heavy.

The assessment of a patient's limitation due to the blood loss mayinclude and evaluation of the patient's blood loss limitation onphysical activities and/or how much the patient's blood loss limitedtheir social and leisure activities. Assessment of the limitations onwork, physical, social and leisure activities may be quantitated as: i)not at all, ii) slightly, iii) moderately, iv) quite a bit, or v)extremely. Alternatively the measure may be quantified in terms of ascale of from one to five where one represents not at all, tworepresents slightly, three represents moderately, four represents quitea bit, and five represents extremely.

Activities limited may include, but are not limited to, walking,standing, climbing stairs, squatting or bending down, playing withchildren and attending school activities. Home management activitiesinclude, but are not limited to, cooking, cleaning, yard work, andlaundry. Leisure activities may include, but are not limited to,dancing, dinner, and movies. Sports activities may include, but are notlimited to, tennis, golf, running, swimming, hiking, biking, boating,baseball, softball, basketball, soccer, fencing, volleyball, and othersports related activities.

Once the initial patient assessment measures have been completed and thepatient has been identified as in need of treatment, the patient isadministered a therapeutically effective treatment regimen of anantifibrinolytic agent. Suitable antifibrinolytic agents contemplatedfor use in the present invention include, but are not limited totranexamic acid, aminocaproic acid, pharmaceutically acceptable salts,esters, derivatives, pro-drugs, metabolites, and analogues of any of theforegoing antifibrinolytic agents.

In certain embodiments the preferred antifibrinolytic agent istranexamic acid. The tranexamic acid utilized in the present inventioncan be formulated into any suitable dosage form. Preferably, thetranexamic acid is in the form of an immediate release tranexamic acidformulation which release is characterized by providing in vitro no morethan 95% by weight of the tranexamic acid or a pharmaceuticallyacceptable salt thereof in about 15 minutes when measured according toUSP 27.

When the preferred antifibrinolytic is tranexamic acid, thetherapeutically effective treatment regimen contemplated by the presentinvention includes administration of a single dose of a tranexamic acidranging from about 650 mg to about 1300 mg three (3) times a day for atleast one day of menstruation, but not more than five days (or 15 singledoses). The treatment regimen may be administered for at least one day,for at least the first two days, for at least the first three days, fordays two through three, for days two to three, for the duration ofmenstruation.

In certain embodiments the tranexamic acid treatment regimen fortreating the heavy menstrual bleeding includes administration of asingle dose of about 650 mg to about 1.3 gm of a immediate releaseformulation of the invention three (3) times a day, wherein theimmediate release formulation provides, in vitro, no more than 95% byweight of the tranexamic acid or a pharmaceutically acceptable saltthereof in about 15 minutes when measured according to USP 27.

In certain other embodiments, the present invention is directed to amethod of evaluating the effectiveness of a treatment regimenadministered for heavy menstrual bleeding and the amelioration ofsymptoms associated with heavy menstrual bleeding including limitationson social, leisure, and physical activities.

Evaluation of the effectiveness of the treatment regimen can beinitiated at the end of the patient's menstrual period, but prior tocompletion of the menstrual cycle. The post-menstruation measuresprovide in part the pharmacology (or therapy assessment) measuredescribed above.

The pharmacology assessment may begin with one or more of the sameseries of measures utilized during the initial patient assessment, whichinclude: a) determining a patient's perceived blood loss volume duringtheir most recent menstrual period; b) determining how much thepatient's blood loss limited their work outside and inside the home; c)determining how much the patient's blood loss limited their physicalactivities; d) determining how much the patient's blood loss limitedtheir social and leisure activities; e) determining the specificactivities that were limited by the patient's blood loss.

Alternatively, an evaluation of the effectiveness of the treatmentregimen may require determining the change in the patient's perceivedblood loss during the most recent menstrual period in comparison to theblood loss during the patient's previous menstrual period, measure 1 ofFIG. 4 and/or an assessment of the improvement achieved, measure 6 ofFIG. 4.

For example, a change in the patients perceived blood loss of about oneunit for example from “heavy” to “moderate” or from a score of 3(“heavy”) to a score of 2 (“moderate”) would provide the basis forcontinued treatment. While a perceived loss of less than about one unitwould suggest either a discontinuation of treatment or a second courseafter which the evaluation would be reconsidered. Alternatively, or inaddition to the blood loss assessment, the practitioner may rely on theassessment in which the comparison of perceived loss is assessed as: i)“about the same”, ii) “better”, and iii) “worse”, as prescribed inmeasure 6 in FIG. 4. When a patient's response is “about the same”, analternative treatment regimen may be considered for the next menstrualperiod. The practitioner may also reconsider re-administering the sametreatment regimen for an additional menstrual period and laterre-evaluate. When a patient's response is “better”, the assessment maycontinue by requiring the patient to provide further information aboutthe improvement in menstrual bleeding. For example, the assessment mayinclude “if your menstrual bleeding improved since your last period,please indicate how much” (measure 6 b of the MI of FIG. 4). Answers tothis inquiry about an improvement in menstrual bleeding may require thepatient to provide an answer such as: 1) a very great deal better; ii) agreat deal better; iii) a good deal better; iv) an average amountbetter; v) somewhat better; vi) a little better; or vii) almost thesame, hardly better at all. Alternatively the answers can be scaled on aseven unit scale where “a very great deal better” is assigned a value of7 and “almost the same” is valued as 7.

When a patient's response to measure 6 is “worse”, the inquiry continuesby requiring the patient to provide further data characterizing thechange in menstrual bleeding. For example, the inquiry may determine “ifyour menstrual period worsened since your last period, please indicatehow much” (measure 6 c of MI of FIG. 4). Data for this measure to aworsening in menstrual bleeding may require the patient to provide aranking such as: i) “a very great deal worse”; ii) “a great deal worse”;iii) “a good deal worse”; iv) “an average amount worse”; v) “somewhatworse”; vi) “a little worse”; or vii) “almost the same, hardly worse atall”. As before the answers may be scaled on a seven unit scale where −1is “almost the same” and −7 is “a very great deal worse”.

The comparison of perceived blood loss which results in an improvementof at least about one unit as measured by measure 1 of FIG. 5 and/or anassessment of a perceived blood loss which is “better” as provided inmeasure six of FIG. 1 may proceed by assessing whether the improvement“was a meaningful or an important change” to the patient (measure 6 c ofMI of FIG. 4).

The information obtained about the “improvement” or “worsening” inmenstrual bleeding allows the practitioner to make an evaluation of theeffectiveness of the treatment regimen which correlates with the changein blood loss as measured by the alkaline hematin test and demonstratedwith clinical trial data.

The method for evaluating the effectiveness of a treatment regimen ofthe present invention may be repeated after each menstrual period. Thedata obtained from the initial patient assessment and the subsequentpharmacology (therapy assessment) can be stored into a computer databaseand utilized for future diagnostic and/or evaluation purposes.

In certain other embodiments, the present invention is directed to amethod of treating heavy menstrual bleeding. The method involving,evaluating symptomatic data gathered from the measures individually orcollectively as described in FIG. 4. (items one through four and six asdiscussed above) to determine the need for therapy and thenadministering, to a patient in need, a therapeutically effectivetreatment regimen of an antifibrinolytic agent, e.g., a release modifiedtranexamic acid formulation or a bioequivalent immediate releaseformulation of the invention, wherein the treatment regimen is to beadministered for part or for the duration of menstruation, but no longerthan 5 days during the patient's menstrual cycle.

The present invention is further described with regard to the followingexamples.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS

The invention will be further appreciated with respect to the followingnon-limiting examples. Other variations or embodiments of the inventionwill also be apparent to one of ordinary skill in the art from the abovedescriptions and examples. Thus, the forgoing embodiments are not to beconstrued as limiting the scope of this invention.

EXAMPLE 1

In Example 1, immediate release 650 mg tranexamic acid tablets wereprepared having the ingredients listed in Table 1 below:

TABLE 1 Quantity per batch Quantity per Ingredient (kg) tablet (mg)Active Ingredient Tranexamic Acid, EP (650 mg/tab) 84.50 650.0 InactiveIngredients Microcrystalline Cellulose, NF 5.753 44.25 (Avicel PH 101)Microcrystalline Cellulose, NF 10.660 82.00 (Avicel PH 102) ColloidalSilicon Dioxide, NF 0.0975 0.75 Pregelatinized Corn Starch, NF 6.43549.50 Croscarmellose Sodium, NF 19.50 15.00 Povidone, USP (K value range29-32) 4.680 36.00 Stearic Acid, NF (powder) 2.340 18.00 MagnesiumStearate, NF (powder) 0.585 4.50 Purified Water, USP* 17.550 135.00 FilmCoating (Inactive Ingredients)** Opadry White YS-1-7003 4.110 — PurifiedWater, USP 36.990 — *Purified water is removed during processing **6 kgexcess prepared to account for losses during transferThe formulation of Example 1 was prepared as follows:

-   -   1. Weigh all ingredients and keep in moisture resistant        containers until ready for use.    -   2. Measure water into a container. Mix povidone at medium speed        until completely dissolved.    -   3. Add tranexamic acid, microcrystalline cellulose (MCC),        pregelatinized corn starch, and colloidal silicon dioxide to the        high shear mixer.    -   4. Mix using impeller only.    -   5. Mix for an additional time (impeller only). Add all of the        povidone solution during this mixing step.    -   6. Mix until adequately granulated (impeller and chopper).        Proceed only when desired granulation has been achieved. Add        additional water if necessary.    -   7. Dry the granulation to moisture content of NMT 1.2%.    -   8. Pass the granulation through the oscillating granulator        equipped with a #30 mesh screen. Weigh the granulation. Add        granulation to the V-Blender.    -   9. Add the croscarmellose sodium and MCC to the V-Blender and        blend.    -   10. Pass magnesium stearate and stearic acid through oscillating        granulator equipped with a #40 mesh screen. Add magnesium        stearate and stearic acid to the V-blender and blend.    -   11. Perform specified physical property testing. Proceed to        compression.    -   12. Compress tablets.    -   12. After compression, spray coat the compressed dosage forms        with the Opadry White in water.

EXAMPLE 2

Modified release 650 mg tranexamic acid tablets were prepared having theingredients listed in the Table 2 below:

TABLE 2 Quantity Quantity per batch per tablet Ingredient (kg) (mg)Active Ingredient Tranexamic Acid, EP 84.50 650.0 Inactive IngredientsMicrocrystalline Cellulose NF (Avicel PH 101) 5.753 44.25 ColloidalSilicon Dioxide NF 0.0975 0.75 Pregelatinized Corn Starch, NF 6.43549.50 Hypromellose, USP (Methocel K3 Premium LV) 19.110 147.00 Povidone,USP (K value range 29-32) 4.680 36.00 Stearic Acid, NF (powder) 2.34018.00 Magnesium Stearate, NF (powder) 0.585 4.50 Purified Water USP*17.550 135.00 *Purified water is removed during processingThe formulation of Example 2 was prepared as follows:

-   -   1. Weigh all ingredients and keep in moisture resistant        containers until ready for use.    -   2. Measure water into a container. Mix povidone at medium speed        until completely dissolved.    -   3. Add tranexamic acid, microcrystalline cellulose (MCC),        pregelatinized corn starch, and colloidal silicon dioxide to the        high shear mixer.    -   4. Mix using impeller only.    -   5. Mix for an additional time (impeller only). Add all of the        povidone solution during this mixing step.    -   6. Mix until adequately granulated (impeller and chopper).        Proceed only when desired granulation has been achieved. Add        additional water if necessary.    -   7. Dry the granulation to moisture content of NMT 1.2%.    -   8. Pass the granulation through the oscillating granulator        equipped with a #30 mesh screen. Weigh the granulation. Add        granulation to the V-Blender.    -   9. Add the hypromellose USP Methocel K3 Premium to the        V-blender. Blend.    -   10. Pass magnesium stearate and stearic acid through oscillating        granulator equipped with a #40 mesh screen. Add magnesium        stearate and stearic acid to the V-blender and blend.    -   11. Perform specified physical property testing. Proceed to        compression.    -   12. Compress tablets to desired weight.

EXAMPLE 3

In Example 3, modified release 650 mg tranexamic acid tablets wereprepared as in Example 1 and coated with a film coating similar to theimmediate release tablets of Example 2. The ingredients are listed inTable 3 below:

TABLE 3 Quantity Quantity per batch per tablet Ingredient (kg) (mg)Active Ingredient Tranexamic Acid, EP 84.50 650.0 Inactive IngredientsMicrocrystalline Cellulose NF (Avicel PH 101) 5.753 44.25 ColloidalSilicon Dioxide NF 0.0975 0.75 Pregelatinized Corn Starch, NF 6.43549.50 Hypromellose, USP (Methocel K3 Premium LV) 19.110 147.00 Povidone,USP (K value range 29-32) 4.680 36.00 Stearic Acid, NF (powder) 2.34018.00 Magnesium Stearate, NF (powder) 0.585 4.50 Purified Water USP*17.550 135.00 Film Coating (Inactive Ingredients)** Opadry WhiteYS-1-7003 4.305 — Purified Water, USP 38.750 — *Purified water isremoved during processing **6 kg excess prepared to account for lossesduring transfer

EXAMPLE 3A

Example 3A, delayed release 650 mg tranexamic acid tablets were preparedhaving the ingredients listed in Table 3A below:

TABLE 3A Quantity Quantity per batch per tablet Ingredient (kg) (mg)Active Ingredient Tranexamic Acid, EP 84.50 650.0 Inactive IngredientsMicrocrystalline Cellulose NF (Avicel PH 101) 5.753 44.25Microcrystalline Cellulose NF (Avicel PH 102) 10.660 82.00 ColloidalSilicon Dioxide NF 0.0975 0.75 Pregelatinized Corn Starch, NF 6.43549.50 Croscarmellose Sodium NF 19.50 15.00 Povidone, USP (K value range29-32) 4.680 36.00 Stearic Acid, NF (powder) 2.340 18.00 MagnesiumStearate, NF (powder) 0.585 4.50 Purified Water USP* 17.550 135.00 FilmCoating (Inactive Ingredients)** Acryl-Eze (930185359) 12.90 — SiliconeEmulsion, 30% 0.323 — Purified Water, USP 51.271 — *Purified water isremoved during processing; mg per tablet is based on theoreticalspecific gravity of 1.0 g/ml **6 kg excess prepared to account forlosses during transferThe formulation of Example 3A was prepared as follows:

-   -   1. Weigh all ingredients and keep in moisture resistant        containers until ready for use.    -   2. Measure water into a container. Mix povidone at medium speed        until completely dissolved.    -   3. Add tranexamic acid, microcrystalline cellulose (MCC),        pregelatinized corn starch, and colloidal silicon dioxide to the        high shear mixer.    -   4. Mix using impeller only.    -   5. Mix for an additional time (impeller only). Add all of the        povidone solution during this mixing step.    -   6. Mix until adequately granulated (impeller and chopper).        Proceed only when desired granulation has been achieved. Add        additional water if necessary.    -   7. Dry the granulation to moisture content of NMT 1.2%.    -   8. Pass the granulation through the oscillating granulator        equipped with a #30 mesh screen. Weigh the granulation. Add        granulation to the V-Blender.    -   9. Add the croscarmellose sodium and MCC to the V-Blender and        blend.    -   10. Pass magnesium stearate and stearic acid through oscillating        granulator equipped with a #40 mesh screen. Add magnesium        stearate and stearic acid to the V-blender and blend.    -   11. Perform specified physical property testing. Proceed to        compression.    -   12. Compress tablets.    -   13. After compression, spray coat the compressed dosage forms        with the film coating.

Dissolution results for the delayed release formulation of Example 3A(in base stage) are listed below in Table 3B.

Dissollution Results for the Delayed Release Formulation (In Base Stage)

TABLE 3B Time (min.) Dissolution (%) Standard Deviation 15 16% ±6.01387330 89% ±14.06769 45 95% ±2.810694 60 97% ±2.345208

EXAMPLE 4 Bioavailability and Bioequivalence Evaluation

In Example 4, a comparative, randomized, single dose, 4-way CrossoverAbsolute Bioavailability (BA) and Bioequivalence (BE) study ofTranexamic Acid Tablet Formulations prepared in accordance with Examples1 and 2 in Healthy Adult Women Volunteers under Fasting Conditions wasperformed. The objective was to assess the bioequivalence of a 650 mgimmediate release tablet formulation prepared in accordance with Example1 compared to the modified release tablet formulation of tranexamic acidprepared in accordance with Example 2, and to determine thebioavailability of the tablet formulations to the approved IV (1 g)formulation Cyklokapron® by Pharmacia & Upjohn. The design was arandomized, 4-way crossover, comparative BE and BA determination. Alloral doses administered were 1.3 g. Twenty-eight (28) healthynon-smoking adult female volunteer subjects were enrolled in the study.Sample size was calculated assuming a 25% CV in AUC_(inf). The studyendpoints were the 90% confidence intervals of the ratio ofleast-squares means of the pharmacokinetic parameters AUC_(0-t).AUC_(inf) and C_(max) of the modified release formulation to theimmediate-release formulation from serum concentration-time data drawnup to 36 hours after a single dose of drug. In addition, thebioavailability of the tablet formulations were calculated. Smokers,oral contraceptive users, those with a previous history ofthromboembolic events and altered vision were excluded from the study.ECG monitoring was performed before, during and after the estimatedtimes of peak serum tranexamic acid concentrations exposure. Adverseevents were captured and recorded throughout the trial period.

In the study, subjects were randomized to receive single oral 1.3 g(2×650 mg tablets) dose of tranexamic acid in tablet forms whichincluded a modified release dosage form and an immediate release dosageform. Subjects were also administered a single 1 g (10 ml) IV solutionof tranexamic acid (100 mg/ml concentration).

A summary of the pharmacokinetic results from the study of Example 4 arelisted in the tables below.

TABLE 4 Summary of Results - Tranexamic Acid in Plasma PharmacokineticParameters (N = 26) ln AUC 0-t* ln AUCinf* ln Cmax* (mcg · h/mL) (mcg ·h/mL) (mcg/mL) Modified Release formulation Mean 66.703 69.642 11.251088CV 26.8 27.2 29.1 N 26 24 26 Immediate Release formulation Mean 70.15772.656 12.260414 CV 16.2 16.4 23.0 N 26 24 26 Least-Squares Mean:Modified Release 66.935 68.891 11.321919 Immediate Release 70.051 72.41112.258222 Ratio of 95.6 95.1 92.4 Least-Squares Mean (modifiedrelease/immediate release)% *For ln-transformed parameters, the antilogof the mean (i.e. the geometric mean) is reported. AUCinf, kel,half-life and F could not be estimated for some subjects.

TABLE 5 Summary of Results - Tranexamic Acid in Plasma PharmacokineticParameters (N = 26) Tmax Half-life kel F (h) (h) (1/h) (%) ModifiedRelease formulation Mean 2.942 11.370 0.06300 44.93 CV 22.7 17.6 19.425.3 n 26 26 26 24 Immediate Release formulation Mean 2.808 11.0130.06438 46.04 CV 20.8 15.5 15.3 16.1 n 26 24 24 24

TABLE 6 Summary of Results - Tranexamic Acid in Plasma PharmacokineticParameters (N = 26) Ln AUC 0-t* ln AUCinf* ln Cmax* (mcg · h/mL) (mcg ·h/mL) (mcg/mL) 90% Confidence Intervals (Modified release/Immediaterelease)% lower limit: 87.8% 87.4% 84.0% upper limit: 104.0% 103.5%101.6% p-Value (ANOVA) Modified vs Immediate 0.3721 0.3259 0.1676 Period0.0704 0.0499 0.0356 Sequence 0.7734 0.7978 0.8207 Intrasubject CV %18.3 17.4 20.6 *For ln-transformed parameters, the antilog of the mean(i.e. the geometric mean) is reported. AUCinf, kel, half-life and Fcould not be estimated for some subjects. AUC 0-t is the area under theplasma concentration versus time curve, from time 0 to the lastmeasurable concentration, as calculated by the linear trapezoidalmethod.

Concentration-time profiles for the study of Example 4 are presented onsemi-log and linear scale over 36 hours and are depicted in FIGS. 1 and2.

The following pharmacokinetic parameters in the table below werecalculated for tranexamic acid in plasma for the study of Example 4.

-   -   MRT: The mean residence time (MRT) after intravenous        administration of tranexamic acid was determined using the        equation,

AUMC/AUC+infusion time/2,

-   -    where the AUMC is the area under the moment-time curve    -   MTT: Following oral administration of the Modified Release and        Immediate Release formulations, the mean transit time (MTT) of        tranexamic acid was calculated by dividing the AUMC by the AUC.    -   MAT: The mean absorption time (MAT) for the two formulations was        derived by subtracting the MRT from the MTT.

Mean (±SD) results are presented in the table below:

TABLE 7 IV Modified Release Immediate Release MRT (hours) 3.51 ± 0.38N/A N/A MTT (hours) N/A 7.70 ± 0.72 7.21 ± 1.01 MAT (hours) N/A 4.18 ±0.70 3.70 ± 0.94

The mean transit time (MTT) and mean absorption time (MAT) of theModified Release formulation of tranexamic acid was approximately 30minutes longer than that observed for the Immediate Release formulation.

The most frequently reported adverse events from the study of Example 4are listed in the table below. The table lists the number of subjectsreporting adverse events, and the percentage of subjects is inparentheses.

TABLE 8 Treatment Modified Immediate IV solution Release Release (10 ×(2 × 650 mg) (2 × 650 mg) 100 mg/ml) Adverse Events (n = 27) (n = 27) (n= 27) Headache  4 (15%)  7 (26%)  7 (26%) Nausea 0 (0%) 2 (7%) 10 (37%)Dizziness 0 (0%) 0 (0%) 11 (41%) Feeling Hot 0 (0%) 0 (0%)  6 (22%)Nasal Congestion 2 (7%) 1 (4%) 1 (4%) Cough 0 (0%) 0 (0%) 2 (7%) Urineodor abnormal 2 (7%) 0 (0%) 1 (4%)

Dissolution Results for Immediate Release and Modified ReleaseFormulations prepared in accordance with Examples 1 and 2 respectivelyused in the study of Example 3 tested under USP-27 Apparatus Type IIPaddle Method@50 RPM in 900 ml water at 37±0.5° C. are listed in thetables below.

TABLE 9 Dissolution Results for the Immediate Release Formulation inTable 1. Time (min.) Dissolution (%) Standard Deviation 15 58.0%±9.521905 30 96.0% ±10.2697 45 102.0% ±0.408248 60 104.0% ±1.032796

TABLE 10 Dissolution Results for the Modified Release Formulation inTable 2 Time (min.) Dissolution (%) Standard Deviation 15 21.0%±1.414214 30 40.0% ±2.810694 45 58.0% ±3.600926 60 73.0% ±3.81663 9098.0% ±2.097618

CONCLUSIONS

The ratios of least-squares means and the 90% confidence intervalsderived from the analyses of the ln-transformed pharmacokineticparameters AUC_(0-t), AUC_(inf) and C_(max) for tranexamic acid inplasma were within the 80-125% Food and Drug Administration (FDA)acceptance range for the modified release formulation versus theimmediate release formulation under fasting conditions.

The absolute bioavailability of the modified release and immediaterelease tablet formulations were 44.93% and 46.04% respectively

Based on these results, the modified release tranexamic acid tabletformulation and the immediate release tranexamic acid formulation arebioequivalent under fasting conditions.

EXAMPLE 4A Comparative Example

In Comparative Example 4A, a 500 mg immediate release tranexamic acidtablet, approved and marketed in Canada under the name Cyklokapron wasobtained and dissolution tested under USP 27 Apparatus Type II PaddleMethod@50 RPM in 900 ml water at 37±0.5° C. The dissolution results arelisted in Table 11 below:

TABLE 11 % dissolved % dissolved % dissolve % dissolved Sample # in 15min. in 30 min. in 45 min. in 60 min. 1 102 104 105 106 2 102 104 105106 3 101 102 102 105 4 99 101 102 103 5 100 102 103 104 6 99 101 102104 Average 101 102 103 105 % RSD 1.4 1.3 1.4 1.1

EXAMPLE 5 Menorraghia Impact Measure Validation

Objective measurements of menstrual blood loss are not practical in thehealthcare setting, and they correlate poorly with a woman's subjectiveassessment of blood loss and its simpact on quality of life [Warner2004; National Collaborating Centre for Women's and Children's Health,2007]. Menorrhagia is a subjective condition and may be practicallydefined as menstrual loss that is greater than the woman feels that shecan reasonably manage. The amelioration of symptoms of heavy menstrualloss are practical efficacy benefits of the treatment are thereforeimportant to measure and validate in a controlled clinical environment.

The MI was evaluated in a sub population of patients enrolled in aclinical trial designed to assess the safety and efficacy of modifiedrelease tranexamic acid formulation (Example 2) at an oral dose of 3.9 gadministered daily for up to 5 days during each menstrual period (Whilethe present study was conducted utilizing the modified releasetranexamic acid formulation described herein in Example 2, theeffectiveness of the MI can also be evaluated utilizing the immediaterelease and delayed release formulations described herein). Two groupsof patients were used to assess the MI, one group of patients were thosediagnosed with menorrhagia and undergoing treatment. The second groupwas an age matched normal group. The sub-study was designed: to collectsufficient quantitative data to support the construct-related validationof the MI measures; to collect sufficient quantitative data to supportthe assessment of meaningful/important change in blood loss to thewomen; to conduct a test/retest evaluation of the instrument, and toaddress the reliability of the MI measures.

Study Methods

Development of the MI began with a review of the literature focusing onthe methods used to collect qualitative data from menorrhagia patients.Qualitative interviews with patients determined which symptomaticconcepts were most important to women and could be included in a draftImpact Measure. Cognitive debriefing interviews to evaluate patientunderstanding of items led to the synthesis of a patient-basedinstrument for assessing the impact of limitations caused by heavymenstrual bleeding. Published measures were used in the evaluation ofthe psychometric properties of the Menorrhagia Instrument to assessConstruct-Related Validity. The reference measures include, the RutaMenorrhagia Questionnaire [Ruta 1995] and the Medical Outcomes StudyShort-Form 36 Item Health Status Instrument (SF-36) [Ware 1992]. Scoringof the standardized measures followed published algorithms, Table 12.

TABLE 12 Descriptions of Instruments used in this study Measure ScoreGenerated Score Ranges Menorrhagia Impact Blood Loss Severity (Q1) 1(light) thru 4 (very heavy) Measure (MI) Limitation Work outside orinside the home (Q2) 1 (not at all) thru 5 (extremely) Physicalactivities (Q3) 1 (not at all) thru 5 (extremely) Social or leisureactivities (Q4) 1 (not at all) thru 5 (extremely) Activity list (Q5)[Descriptive] Change in blood loss (follow-up) (Q6, 6a, 6b) [15-ptscale: 0 = no change, 1-7 improve, 1-7 worse] Meaningful/importantchange (Q6c) Y/N Ruta Menorrhagia Global 0 (asymptomatic) - 42 (severe)Questionnaire Specific Physical Function: Impact on work and daily 0(asymptomatic) - 6 (severe) activities (Q9 and Q10) Social Function:Impact on social and leisure 0 (asymptomatic) - 8 (severe) activitiesand sex-life (Q11 and Q12) SF-36 Physical Functioning, Role-Physical,Bodily Pain 0-100 General Health (can be combined to form Physical (100= minimal impairment) Health Component Score); Vitality, SocialFunctioning, Role-Emotional, Mental Health (can be combined to formMental Health Component Score)

Study Design

A total of 262 women completed the MI. The MI measures 1 through 5 wereadministered after subject's baseline period and after the subsequentfirst second, third and sixth treatment periods. The MI measure 6 wasadministered after the first treatment period only. For this validationstudy, only the data collected through Month 1 of treatment was includedin the analyses for the treatment cohort. The MI measures 1-5 wereadministered at baseline and at the subsequent first and secondnon-treatment periods for the subjects in the normal cohort. The MImeasure 6 was administered and data collected at Month 1 and Month 2.The Ruta Menorrhagia Questionnaire, SF-36 Health Survey and the MI werecompleted by the subject before visit procedures were performed. Asubset of at least 50 subjects were asked to return to the study site 7to 10 days after the baseline Visit but before the next menstrual periodstarts to complete the MI a second time.

Treatment Group

A total of 177 patients were enrolled into the sub-study. During thistime period 28 patients withdrew consent, dropped-out, or did notproperly complete MI and were non-evaluable. The 149 patients remainingwere intended to be age matched. The majority of patients in the studywere in their late 30's or early 40's. Because of the difficulty ofenrolling sufficient numbers of women with normal menstrual periods inthis age bracket 18 evaluable patients were not age matched. A total of131 evaluable patients were age matched. A sub-set of 80 evaluablepatients participated in the test/retest segment of the validation. Ofthese patients 11 were evaluable but not age matched. Data from all 80patients were used for statistical evaluation of the test/re-testcorrelations.

Normal Group

A group of women with self reported normal menstrual bleeding comprisedthe pool of normal women eligible for age matching in the study. Anormal was defined as all of the following: a menstrual cycle between 26and 32 days long, and their last (most recently completed) menstrualperiod was seven days or less in duration, the heaviest bleeding wasthree days or less, and the woman classified the bleeding overall as“light” or “moderate” as opposed to “heavy” or “very heavy. Women withnormal periods who were enrolled into the study served as age-matchcontrols for women recruited into the treatment group. Un-matching andre-matching occurred throughout the enrollment period if participants ineither group dropped out of the study, if better re-matching increasedthe total number of matched pairs, or if the age-matched woman withnormal periods did not enroll in the study.

Five women enrolled in the study did not complete the study throughVisit 3. Another five women who did complete the study became‘unmatched’ as the Treatment Group participant they had been matched tobecame non-evaluable. The 131 women who completed the study and remainedmatched are the Validation Sample Normal Group. A total of 51 womencompleted the Retest.

The following Measures were summarized and statistically analyzed:

-   -   MI measure 1—Blood Loss Rating    -   MI measure 2—Limitation of Work Outside or Inside the Home    -   MI measure 3—Limitation of Physical Activities    -   MI measure 4—Limitation of Social or Leisure Activities    -   MI measure 6/6 a/6 b—Menstrual Blood Loss During Last Period    -   MI measure 6 c—Meaningfulness of Change in Menstrual Blood Loss

The statistics include the counts (missing data), mean, standarddeviation, median, inter-quartile range, and minimum/maximum values.Differences in these variables between the treatment and normal cohortswere assessed using analysis of variance.

A p-value <0.05 was required for significance using two-sided hypothesistests; no p-value adjustments were made for the analysis of multipleendpoints. All analyses were performed under SPSS version 11.5 forWindows, and the Stuart-Maxwell test for homogeneity was performed usingStata version 9.0 for Windows.

Validation of the MI was conducted using standardized analyticprocedures found in the FDA Draft Guidance on Patient Reported Outcomesfor Use in Evaluating Medical Products for Labeling Claims andinstrument review criteria developed by the Scientific AdvisoryCommittee of the Medical Outcomes Trust.¹ 1 Scientific AdvisoryCommittee of the Medical Outcomes Trust Assessing health status andquality-of-life instruments: attributes and review criteria. Qual LifeRes. 2002; 11; 193-205

Evaluation of the Menorrhagia Instrument

The MI consisted of 4 individual measures (1-4) that were analyzedseparately for validation. No summative scale was derived. Measure 5,served as descriptive of variables and did not undergo standardvalidation analyses. Measures 6, 6 a and 6 b dealt with menstrual bloodloss relative to the previous menstrual period. The answers to themeasures in the subparts of measure 6, were combined to produce a 15point rating scale. The scale values range from −7 to +7 with −7representing a very great deal worse menstrual blood loss than theprevious period, and +7 representing a very great deal better menstrualblood loss than the previous period. The midpoint (0) represents theperception of about the same menstrual blood loss as the previousperiod.

Test-retest reliability assessed if items produced stable, reliablescores under similar conditions (Guttman, 1945). Reproducibility wasevaluated in a subset of at least 50 from the treatment group and atleast 50 from the normal group 7 to 10 days after the baseline visitusing the intra-class correlation coefficient (ICC, see formula below).Values above 0.70 indicated the stability of an instrument over time.The following formula was used to compute the Intraclass CorrelationCoefficient (ICC):

${I\; C\; C} = \frac{A^{2} + {B^{2}C^{2}}}{A^{2} + B^{2} + D^{2} - \left( \frac{C^{2}}{n} \right)}$where:  A = Standard  deviation  of  baseline  score     B = Standard  deviation  of  Time  2  score      C = Standard   deviation  of  change  in  score D = mean  of  change  in  score     n = number  of  respondents     

The data for each of the measures was above 0.70. In the testpopulation, n=88, values of 0.72(0.60-0.81), 0.75(0.64-0.83),0.77(0.67-0.84) and 0.76(0.66-0.84) for measures 1 to 4 respectively.The aged matched normal values where n=51 were 0.77(0.63-0.86),0,67(0.49-0.80), 0.75(0.60-0.85) and 0.86(0.77-0.92) respectively.

Construct-Related Validity was established when relationships amongitems, domains, and concepts conform to what was predicted by theconceptual framework for the instrument. This includes convergent,discriminant, and known-groups validity. Convergent and discriminantvalidity was present where measures of the same construct are morehighly related and measures of different constructs were less related.To assess convergent and discriminant validity, Pearson's correlationcoefficients were computed between each MI measure and items and scalesfrom the SF-36 and the Ruta Menorrhagia Questionnaire included in thestudy design and administered at the same visit. The followinghypotheses were tested.

The MI Blood Loss Measure (#1) will have a stronger association with theRuta Menorrhagia Questionnaire (RMQ) Man to the SF-36 subscales.

The MI Physical Activity Limitation Measure (#3) will have a strongerassociation with the RMQ Physical Function scale, the SF-36 Physicaldomain, the SF-36 Role-Physical domain, and SF-36 Physical ComponentSummary score than the Ruta Social, SF-36 Social, and SF-36 Vitalitydomains.

The MI Social/Leisure Activity Limitation will have a have strongerassociations with the RMQ Social Function scale and the SF-36 SocialFunction domain than the RMQ Physical, the SF-36 Physical and SF-36Bodily Pain domains.

For convergent validity, the correlations of MI measures with Rutasubscales, SF-36 subscales, and diary data are shown in Table 13. TheRuta global score was highly correlated with each MI measures (range0.757-0.809). The correlations of items with the SF-36 subscales werelow to moderate, which is to be expected since the SF-36 is not adisease-specific measure, but rather a more generic health statusmeasure unable to detect differences between a normal population and apopulation of women with menorrhagia. The MI measures were more stronglycorrelated with the SF-36 Physical and Role Physical subscales thanother SF-36 subscales.

TABLE 13 Correlations Between Menorrhagia Instrument Patient ReportedOutcome (PRO) Measures and Ruta/SF-36/Diary MI MI measure 2 measure 1Limit work MI measure 3 MI measure 4 Blood outside or Limit physicalLimit social or Loss inside home activity leisure activity Ruta - 0.767 0.785 (0.000)  0.807 (0.000)  0.809 (0.000) Global (0.000) Ruta - 0.512 0.682 (0.000)  0.646 (0.000)  0.664 (0.000) Physical (0.000) Fx Ruta -0.606  0.634 (0.000)  0.659 (0.000)  0.683 (0.000) Social Fx (0.000)SF-36 - −0.229 −0.234 (0.000) −0.264 (0.000) −0.273 (0.000) Physical(0.000) Fx SF-36 - −0.118 −0.194 (0.002) −0.200 (0.001) −0.261 (0.000)Social Fx (0.057) SF-36 - −0.200 −0.279 (0.000) −0.258 (0.000) −0.303(0.000) Role (0.001) Physical SF-36 - −0.143 −0.193 (0.002) −0.248(0.000) −0.250 (0.000) Vitality (0.021) SF-36 - −0.087 −0.168 (0.006)−0.192 (0.002) −0.205 (0.001) Bodily (0.163) Pain SF-36 - −0.190 −0.271(0.000) −0.285 (0.000) −0.275 (0.000) PCS (0.002)

The data supported the hypothesis that the MI Blood Loss measure (#1)had a stronger association with the Ruta global score than to the SF-36subscales. While the hypothesis that MI measure #3 (Physical ActivityLimitation) would be strongly associated to the physical domains of theRMQ (r=0.65) and SF-36 (r=0.26) was confirmed, this measure was alsostrongly correlated to the RMQ Social Functioning (r=0.66). MI measure#4 (Social or Leisure Activity Limitation) was highly correlated to theRMQ Social (r=0.68) and moderately associated with the SF-36 SocialFunctioning domain.

Known-groups validity determined the ability of the instrument todiscriminate between groups of subjects known to be distinct. Theability of the MI items to discriminate among known groups was assessedby comparing the 4 items (1 thru 4) to responses from the two groups(treatment and normal) at baseline. Differences in these variables,between the treatment and normal groups, were assessed using analysis ofvariance. A p-value <0.05 was required for significance using two-sidedhypothesis tests; no p-value adjustments was made for the analysis ofmultiple endpoints.

For each MI measure, the mean score for the treatment group wassignificantly different than the mean score for the normal group(p<0.001). The treatment group scores were higher for each individualmeasure, indicating greater limitation as a result of their excessivemenstrual blood loss (see Table 14).

TABLE 14 Known-Groups Validity of the MI AGE MATCH Treatment NORMALCohort Cohort N Mean St. Dev. N Mean St. Dev. F (sig.)¹ MI Self- 1313.25 0.61 131 2.10 0.61 234.727 measure 1 perceived (<0.001) blood lossMI Limit you in 131 3.04 0.99 131 1.34 0.59 286.864 measure 2 your work(<0.001) MI Limit you in 131 3.28 0.95 131 1.49 0.72 299.011 measure 3your physical (<0.001) activities MI Limit you in 131 3.05 1.06 131 1.370.72 227.312 measure 4 your (<0.001) social/leisure activities

The ability to detect change required that values for the item orinstrument change when the concept it measures changed. In order tomeasure the MI items ability to detect change, longitudinal data wereevaluated focusing primarily on the changes from baseline to month 1.Differences in proportions and comparisons between treatment and normalgroups were compared using chi-square statistics (the Stuart-Maxwelltest testing marginal homogeneity for all categories simultaneously).Cohen Effect Size statistics were also compared between the treatmentand normal groups. The Cohen Effect Size was computed by taking the meanchange in measure score (baseline to month 1) and dividing that by thestandard deviation of mean baseline score². 2 Cohen, J. J. (1988).Statistical power analysis for the behavioral sciences (p. 8). Erlbaum:Hillsdale, N.J.

Ability to detect change was described for each item in Tables 15A-D byindicating the distribution of baseline and month 1 response optionpairs for all patients. Change in responses from baseline to month 1 wastested using the Stuart-Maxwell test. For the treatment group, there wassignificant change in responses to each measure from baseline to monthone (p<0.001). For the normal group, none of the items had significantchanges in responses from baseline to month one. FIG. 5 illustrates thedistribution of responses to measure 1 at baseline and at month one. Inthe treatment group, the proportion reporting light or moderate bleedingas measured with item 1, increased from baseline to month 1, and in thenormal group this proportion changed very little.

TABLE 15A Sensitivity to change of the MI Measure 1 Stuart- Month 1Maxwell test Response Very of Cohort category Light Moderate Heavy Heavyassociation Treatment Baseline Light 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)59.09 (p < 0.001) Moderate 0 (0.0%) 8 (6.3%) 4 (3.2%) 0 (0.0%) Heavy 3(2.4%) 41 (32.5%) 24 (19.0%) 2 (1.6%) Very 2 (1.6%) 18 (14.3%) 13(10.3%) 11 (8.7%)  Heavy Normal Baseline Light 9 (6.9%) 5 (3.8%) 0(0.0%) 0 (0.0%)  6.35 (p = 0.130) Moderate 12 (9.2%)  77 (59.2%) 4(3.1%) 0 (0.0%) Heavy 0 (0.0%) 9 (6.9%) 8 (6.2%) 2 (1.5%) Very 0 (0.0%)2 (1.5%) 2 (1.5%) 0 (0.0%) Heavy

TABLE 15B Sensitivity to change of the MI Measure 2 Month 1 Stuart-Maxwell Response Quite test of Cohort category Not at all SlightlyModerately a bit Extremely association Treatment Baseline Not at all 5(4.0%) 0 (0.0%) 1 (0.8%) 1 (0.8%) 0 (0.0%) 53.33 (p < 0.001) Slightly 12(9.5%)  11 (8.7%)  2 (1.6%) 1 (0.8%) 0 (0.0%) Moderately 17 (13.5%) 26(20.6%) 14 (11.1%) 1 (0.8%) 0 (0.0%) Quite a bit 2 (1.6%) 8 (6.3%) 5(4.0%) 9 (7.1%) 0 (0.0%) Extremely 3 (2.4%) 3 (2.4%) 3 (2.4%) 1 (0.8%) 1(0.8%) Normal Baseline Not at all 89 (69.0%) 5 (3.9%) 1 (0.8%) 0 (0.0%)0 (0.0%)  2.86 (p = 0.517) Slightly 8 (6.2%) 13 (10.1%) 4 (3.1%) 2(1.6%) 0 (0.0%) Moderately 0 (0.0%) 3 (2.3%) 4 (3.1%) 0 (0.0%) 0 (0.0%)Quite a bit 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) Extremely 0(0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

TABLE 15C Sensitivity to change of the MI Measure 3 Stuart- Month 1Maxwell Response Not at Quite test of Cohort category all SlightlyModerately a bit Extremely association Treatment Baseline Not at all 0(0.0%) 0 (0.0%) 1 (0.8%) 0 (0.0%) 0 (0.0%) 64.58 (p < 0.001) Slightly 12(9.5%)  12 (9.5%)  1 (0.8%) 1 (0.8%) 0 (0.0%) Moderately 14 (11.1%) 20(15.9%) 11 (8.7%)  3 (2.4%) 0 (0.0%) Quite a bit 6 (4.8%) 17 (13.5%) 9(7.1%) 5 (4.0%) 0 (0.0%) Extremely 5 (4.0%) 2 (1.6%) 2 (1.6%) 3 (2.4%) 2(1.6%) Normal Baseline Not at all 72 (55.4%) 9 (6.9%) 0 (0.0%) 0 (0.0%)0 (0.0%)  1.99 (p = 0.708) Slightly 14 (10.8%) 18 (13.8%) 3 (2.3%) 1(0.8%) 0 (0.0%) Moderately 0 (0.0%) 6 (4.6%) 4 (3.1%) 1 (0.8%) 0 (0.0%)Quite a bit 0 (0.0%) 1 (0.8%) 1 (0.8%) 0 (0.0%) 0 (0.0%) Extremely 0(0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

TABLE 15D Sensitivity to change of the MI Measure 4 Month 1 Stuart-Response Not at Quite Maxwell test Cohort category all SlightlyModerately a bit Extremely of association Treatment Baseline Not at all6 (4.8%) 3 (2.4%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 60.77 (p < 0.001) Slightly16 (12.7%) 10 (7.9%)  0 (0.0%) 2 (1.6%) 0 (0.0%) Moderately 19 (15.1%)14 (11.1%) 12 (9.5%)  2 (1.6%) 1 (0.8%) Quite a bit 5 (4.0%) 14 (11.1%)4 (3.2%) 6 (4.8%) 0 (0.0%) Extremely 3 (2.4%) 4 (3.2%) 1 (0.8%) 3 (2.4%)1 (0.8%) Normal Baseline Not at all 84 (64.6%) 11 (8.5%)  0 (0.0%) 0(0.0%) 0 (0.0%)  1.71 (p = 0.807) Slightly 10 (7.7%)  14 (10.8%) 2(1.5%) 0 (0.0%) 0 (0.0%) Moderately 0 (0.0%) 4 (3.1%) 2 (1.5%) 0 (0.0%)0 (0.0%) Quite a bit 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (1.5%) 0 (0.0%)Extremely 1 (0.8%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

The amount of change in each item from baseline to month 1 is shown inTable 16. For the treatment group, the mean change in response frombaseline to month 1 ranged from −0.76 to −1.16 for the four items. Thecalculated effect size shows this amount of change for each item rangedfrom −0.9 to −1.2. For the normal group, the mean change in responsefrom baseline to month 1 ranged from 0.03 to −0.12 for the four items.The effect size for each item ranged from 0.053 to −0.197. This analysisshows a large response in patients undergoing treatment and little to noresponse in normal women who have received no treatment. This instrumentis capable of identifying the perceived improvement in menstrual bloodloss.

TABLE 16 Sensitivity to Change of MI Effect Size BASELINE MONTH 1 CHANGESt St St Effect Menorrhagia Item n Mean Dev n Mean Dev n Mean Dev Size¹Item 1 Self-perceived blood loss 126 3.25 0.62 126 2.49 0.73 126 −0.760.84 −1.226 Item 2 Limit you in your work 126 3.05 0.99 126 2.12 0.99126 −0.93 1.13 −0.939 Item 3 Limit you in your physical 126 3.29 0.95126 2.13 1.00 126 −1.16 1.17 −1.221 activities Item 4 Limit you in your126 3.06 1.06 126 2.00 1.04 126 −1.06 1.19 −1.000 social/leisureactivities BASELINE St CHANGE St Effect Menorrhagia Item n Mean Dev nMean n Mean Dev Size Item 1 Self-perceived blood loss 130 2.10 0.61 1301.98 130 −0.12 0.56 −0.197 Item 2 Limit you in your work 129 1.32 0.57129 1.35 129 0.03 0.50 0.053 Item 3 Limit you in your physical 130 1.490.72 130 1.43 130 −0.06 0.57 −0.083 activities Item 4 Limit you in your130 1.37 0.72 130 1.33 130 −0.04 0.58 −0.056 social/leisure activities

Responses from treatment group participants were divided based on twoseparate responder definitions. In the first definition, a responder wasa patient indicating a one-category change in MI measure 1. In thesecond definition, a responder was a patient who entered the study as“Very heavy” or “Heavy” (MI measure 1) and then, following treatment(month 1), indicated being “Moderate” or “Light”. When the treatmentgroup was analyzed using the first responder definition, 69 (90%) of the77 responders reported improvement and 63 (91%) of these rated thisimprovement as “a meaningful change”. Thirty-five (71%) of the 49non-responders reported improvement and 35 (92%) rated their change as“a meaningful change”.

When the treatment group was analyzed using the second responderdefinition, 57 (89%) of the 64 responders reported improvement, and 52(91%) reported their change to be meaningful. Forty-seven (76%) of the62 non-responders reported improvement, and 45 (90%) reported theirchange to be meaningful. Among the normal group, 96 (73%) of 130patients reported no change. Twenty-one (16%) reported improvement, and13 (10%) reported worsening. Of the patients reporting change, 15 (44%)rated the change as “a meaningful change”.

For those women on treatment who reported a meaningful improvement(78.6%/), MI items 3 and 4 showed the greatest treatment effect withimprovements of 1.29 and 1.17, respectively. As expected, the majorityof the Normal cohort (73.3%) reported no change in their menstrualperiod.

EXAMPLES 5A-BE Summary of Clinical Findings

The efficacy and safety of the tranexamic acid modified release tablets(TAX MR.) in the treatment of HMB was demonstrated in one 3-cycletreatment and one 6-cycle treatment, randomized, double-blind,placebo-controlled study. In these studies, the primary outcome measurewas menstrual blood loss (MBL), measured using a validated menstrualblood loss method. The key secondary outcome measures were based onresponses to items on the Menorrhagia Instrument (MI), a validateddisease-specific patient-reported outcome instrument that measuredLimitations in Social or Leisure activities and Limitations in PhysicalActivities. Large stains (soiling beyond the undergarment) and sanitaryproduct use were also included as secondary outcome measures. In thesestudies, subjects were 18 to 49 years of age with a mean age ofapproximately 40 years and a BMI of approximately 32 kg/m2. On average,subjects had an HMB history of approximately 10 years and 40% hadfibroids as determined by transvaginal ultrasound. About 20% weresmokers and approximately 50% reported using alcohol. Approximately 70%were Caucasian, 25% were Black, and 5% were Asian, Native American,Pacific Islander, or Other. Seven percent (7%) of subjects were ofHispanic origin. In addition, approximately 18% of subjects were takingmultivitamins and 7% of subjects were taking iron supplements.

EXAMPLE 5A Three-Cycle Treatment Study

This study compared the effects of two doses of tranexamic acid modifiedrelease tablets (1.95 g and 3.9 g given daily for up to 5 days duringeach menstrual period) versus placebo on MBL over a 3-cycle treatmentduration. A total of 304 patients (117 TXA MR 1.95 g/day, 118 TXA MR 3.9g/day, 69 Placebo) were randomized. MBL was significantly reduced inpatients treated with 3.9 g/day TXA MR compared to placebo (mean 3.9g/day TXA MR=65.31 mL [percent MBL reduction=38.6%]; placebo mean=2.98mL [percent MBL reduction=1.9%]; p<0.0001). This reduction met thecriteria for being a clinically meaningful improvement (MBL≧50 ml) and ameaningful improvement to women who participated in the trial (MBL≧36mL). The 1.95 g/day dose did not meet the clinically meaningfulimprovement criteria for efficacy thereby establishing 3.9 g/day TXA MRas the .effective dose.

Tranexamic acid modified release tablets also significantly reducedlimitations on social, leisure, and physical activities as measured byquestions on the MI, and sanitary products used in the 3.9 g/day dosegroup compared to placebo (see Table 17). No significant treatmentdifferences were observed in response rates on the number of largestains.

TABLE 17 Secondary Outcomes in 3-Cycle Study Mean (SD) P-value vs.Outcome Measure N Reduction* Placebo Social and Leisure Activities (MI)3.9 gm/day TXA MR 112 1.10 (1.12) <0.0001 Placebo 66 0.34 (0.85)Physical Activities (MI) 3.9 gm/day TXA MR 112 0.97 (1.03) <0.0001Placebo 66 0.32 (0.80) Sanitary Products Used 3.9 gm/day TXA MR 112 6.36(6.80) <0.0001 Placebo 67 2.40 (6.13) Reduction in Large Stains** 3.9gm/day TXA MR 111   71 (64.0) 0.156 Placebo 67   35 (52.2) *Positivemeans reflect a decrease from baseline **The reduction in large stainsis reported as the number (%) of women who were classified as responders(i.e., subjects who experienced a positive change from baseline)

EXAMPLE 5B Six-Cycle Treatment Study

This study compared the effects of one dose of TXA MR (3.9 g/day) versusplacebo on MBL over a 6-cycle treatment duration. A total of 196patients (123 TXA MR 3.9 g/day, 73 Placebo) were randomized. Replicatingthe results from the 3 cycle treatment study, MBL was significantlyreduced in patients treated with 3.9 g/day TXA MR compared to placebo(mean 3.9 g/day TXA MR=69.6 mL [percent MBL reduction=40.4%]; placebomean=12.6 mL [percent MBL reduction=8.2%]; p<0.0001). This reduction metthe criterion for being a clinically meaningful improvement (MBL≧50 mL)and a meaningful improvement to women (MBL≧36 mL). Limitations onsocial, leisure and physical activities were also significantly reducedin the 3.9 g/day TXA MR dose group compared to placebo (see Table 18).No significant treatment differences were observed in sanitary productsused or in response rates on the number of large stains.

TABLE 18 Secondary Outcomes in 6-Cycle Study Mean (SD) P-value vs.Outcome Measure N Reduction* Placebo Social and Leisure Activities (MI)3.9 gm/day TXA MR 115 0.89 (0.85) <0.0001 Placebo 72 0.38 (0.82)Physical Activities (MI) 3.9 gm/day TXA MR 115 0.90 (0.86) <0.0001Placebo 72 0.35 (0.90) Sanitary Products Used 3.9 gm/day TXA MR 115 5.20(6.39) 0.129 Placebo 72 4.03 (5.94) Reduction in Large Stains** 3.9gm/day TXA MR 115   66 (57.4) 0.453 Placebo 72   37 (51.4) *Positivemeans reflect a decrease from baseline **The reduction in large stainsis reported as the number (%) of women who were classified as responders(i.e., subjects who experienced a positive change from baseline)

While the invention herein disclosed has been described by means ofspecific embodiments and applications thereof, numerous modificationsand variations could be made thereto by those skilled in the art withoutdeparting from the spirit and scope of the present invention. Suchmodifications are understood to be within the scope of the appendedclaims.

1. A method of treating a patient in need of tranexamic acid therapycomprising: orally admnistering to said patient about 1300 mg oftranexamic acid or pharmaceutically acceptable salt thereof in at leastone oral dosage form which provides a mean maximum plasma concentration(C_(max)) of tranexamic acid of about 9 to about 15 mcg/ml after singledose oral administration to humans.
 2. The method of claim 1, whereinsaid at least one oral dosage form provides a mean time to maximumplasma concentration (T_(max)) at about 2 to about 4 hours after oraladministration to humans.
 3. The method of claim 1, wherein the dosageform provides a mean transit time of said tranexamic acid of 7.21±1.01hours.
 4. The method of claim 1, wherein the oral dosage form of claim1, wherein the dosage form provides a mean absorption time of saidtranexamic acid of 3.70±0.94 hours.
 5. The method of claim 1, whereinsaid at least one oral dosage form is two oral dosage forms.
 6. Themethod of claim 1, wherein said patient is a patient suffering frommenorrhagia, conization of the cervix, epistaxis, hyphema, hereditaryangioneurotic edema, a patient with a blood coagulation disorderundergoing dental surgery, or combination thereof.
 7. A oral dosage formcomprising about 650 mg of tranexamic acid or pharmaceuticallyacceptable salt thereof and a pharmaceutically acceptable excipient;said dosage form providing an in-vitro dissolution release rate of thetranexamic acid or pharmaceutically acceptable salt thereof, whenmeasured by a USP 27 Apparatus Type II Paddle Method@50 RPM in 900 mlwater at 37±0.5° C., of at least about 70% by weight tranexamic acidreleased at about 45 minutes.
 8. The oral dosage form of claim 7, whichprovides an in-vitro dissolution release rate of the tranexamic acid orpharmaceutically acceptable salt thereof, when measured by the USP 27Apparatus Type II Paddle Method@50 RPM in 900 ml water at 37±0.5° C. ofabout 0% to about 100% by weight tranexamic acid or pharmaceuticallyacceptable salt thereof released at about 15 minutes, from about 30% toabout 100% by weight tranexamic acid or pharmaceutically acceptable saltthereof released at about 30 minutes, from about 70% to about 95% byweight tranexamic acid or pharmaceutically acceptable salt thereofreleased at about 45 minutes, about 100% by weight tranexamic acid orpharmaceutically acceptable salt thereof released at about 60 minutes.9. The oral dosage form of claim 7, l wherein the dosage form provides amean transit time of said tranexamic acid of 7.21±1.01 hours when orallyadministered across a patient population.
 10. The oral dosage form ofclaim 7, wherein the dosage form provides a mean absorption time of saidtranexamic acid of 3.70±0.94 hours when orally administered across apatient population.
 11. The oral dosage form of claim 7, wherein thepharmaceutically acceptable excipient comprises a diluent.
 12. The oraldosage form of claim 11, wherein said diluent is selected from the groupconsisting of dextrose, sucrose, starch, powdered cellulose, lactose,mannitol, microcrystalline cellulose, and combinations thereof.
 13. Theoral dosage form of claim 7, wherein the pharmaceutically acceptableexcipient comprises a glidant, a surface active agent, a coloring agent,a flavoring agent, a lubricant, or combination thereof.
 14. A method oftreating a patient in need of tranexamic acid therapy comprising: orallyadministering to said patient two dosage forms, each dosage formcomprising about 650 mg of tranexamic acid or pharmaceuticallyacceptable salt thereof and a pharmaceutically acceptable excipient. 15.The method of claim 14, wherein the dosage forms provide a dissolutionrelease rate in-vitro of the tranexamic acid or pharmaceuticallyacceptable salt thereof when measured by the USP 27 Apparatus Type IIPaddle Method@50 RPM in 900 ml water at 37±0.5° C., of least about 70%by weight tranexamic acid released at about 45 minutes.
 16. The methodof claim 14, wherein the dosage forms are administered to said patientthree times a day.
 17. The method of claim 14, wherein thepharmaceutically acceptable excipient comprises a diluent.
 18. Themethod of claim 17, wherein said diluent is selected from the groupconsisting of dextrose, sucrose, starch, powdered cellulose, lactose,mannitol, microcrystlline cellulose, and combinations thereof.
 19. Themethod of claim 14, wherein the pharmaceutically acceptable excipientcomprises a glidant, a surface active agent, a coloring agent, aflavoring agent, a lubricant, or combination thereof.
 20. An oral dosageform comprising tranexamic acid or a pharmaceutically acceptable saltthereof and a pharmaceutically acceptable excipient, said dosage formproviding a bioavailability of said tranexamic acid of greater than 40%.